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Abdalla SM, Koya SF, Rosenberg SB, Stovall IB, Biermann O, Zeinali Z, Cohen GH, Ettman CK, Galea S. Pandemic stressors and mental health indicators in eight countries. Soc Psychiatry Psychiatr Epidemiol 2024; 59:585-598. [PMID: 37587229 DOI: 10.1007/s00127-023-02541-w] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 07/30/2023] [Indexed: 08/18/2023]
Abstract
PURPOSE The Covid-19 pandemic has exacted a significant physical, financial, social, and emotional toll on populations throughout the world. This study aimed to document the association between pandemic stressors and mental health during the pandemic across countries that differ in cultural, geographic, economic, and demographic factors. METHODS We administered an online survey randomly in Brazil, China, Germany, Egypt, India, Indonesia, Nigeria, and the United States from September 2020 to November 2020. This survey included questions on Covid-19-related stressors as well as the Patient Health Questionnaire-2 and the Primary Care PTSD Checklist to screen for depression and post-traumatic stress disorder (PTSD) symptoms, respectively. We performed bivariable and multivariable regression analyses to assess the prevalence and odds ratios of overall depression symptoms and probable PTSD and in relation to stressors across countries. RESULTS Among 8754 respondents, 28.9% (95% CI 27.5-30.0%) experienced depression symptoms, and 5.1% (95% CI 4.5-6.0%) experienced probable PTSD. The highest prevalence of depression symptoms was in Egypt (41.3%, 95% CI 37.6-45.0%) and lowest in the United States (24.9%, 95% CI 22.3-27.7%). The highest prevalence of probable PTSD was in Brazil (7.3%, 95% CI 5.6-9.4%) and the lowest in China (1.2%, 95% CI 0.7-2.0%). Overall, experiencing six or more Covid-19-related stressors was associated with both depression symptoms (OR 1.90, 95% CI 1.46-2.48) and probable PTSD (OR 13.8, 95% CI 9.66-19.6). CONCLUSION The association between pandemic related stressors and the burden of adverse mental health indicators early in the Covid-19 pandemic transcended geographic, economic, cultural, and demographic differences between countries. The short-term and long-term impacts of the pandemic on mental health should be incorporated in efforts to tackle the consequences of Covid-19.
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Affiliation(s)
- Salma M Abdalla
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, 02119, USA.
- Department of Global Health, School of Public Health, Boston University, Boston, MA, USA.
| | - Shaffi Fazaludeen Koya
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, 02119, USA
| | - Samuel B Rosenberg
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, 02119, USA
| | - Isaac B Stovall
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, 02119, USA
| | - Olivia Biermann
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | | | - Gregory H Cohen
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, 02119, USA
| | | | - Sandro Galea
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, 02119, USA
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Amorós Molina Á, Helldén D, Alfvén T, Niemi M, Leander K, Nordenstedt H, Rehn C, Ndejjo R, Wanyenze R, Biermann O. Integrating the United Nations sustainable development goals into higher education globally: a scoping review. Glob Health Action 2023; 16:2190649. [PMID: 36999571 PMCID: PMC10071976 DOI: 10.1080/16549716.2023.2190649] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND In 2015, the United Nations adopted the 2030 Agenda for Sustainable Development, including the 17 Sustainable Development Goals (SDGs). Higher education institutions have a role in raising awareness and building skills among future professionals for implementing the SDGs. This review describes how the SDGs have been integrated into higher education globally. OBJECTIVES Determine how have the SDGs been integrated into higher education globally. Describe the differences in the integration of the SDGs in higher education across high-income countries (HICs) and low- and middle-income countries (LMICs). METHODS Following a scoping review methodology, we searched Medline, Web of Science, Global Health, and Educational Resources Information Center, as well as websites of key institutions including universities, identifying peer-reviewed articles and grey literature published between September 2015 and December 2021. RESULTS We identified 20 articles and 38 grey literature sources. Since 2018, the number of publications about the topic has been increasing. The SDGs were most frequently included in bachelor-level education and disciplines such as engineering and technology; humanities and social sciences; business, administration, and economics. Methods of integrating the SDGs into higher education included workshops, courses, lectures, and other means. Workshops and courses were the most frequent. The methods of integration varied in high-income countries compared to low- and middle-income countries. High-income countries seemed to follow a more academic approach to the SDGs while low- and middle-income countries integrate the SDGs with the aim to solve real-world problems. CONCLUSION This study provides examples of progress in integrating the SDGs into higher education. Such progress has been skewed to high-income countries, bachelor-level initiatives, and certain disciplines. To advance the integration of the SDGs, lessons learned from universities globally should be shared broadly, equitable partnerships formed, and students engaged, while simultaneously increasing funding for these processes.
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Affiliation(s)
| | - Daniel Helldén
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Centre of Excellence for Sustainable Health, Karolinska Institutet in Stockholm, Solna, Sweden
- The Centre of Excellence for Sustainable Health, Makerere University in Kampala, Kampala, Uganda
| | - Tobias Alfvén
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Centre of Excellence for Sustainable Health, Karolinska Institutet in Stockholm, Solna, Sweden
| | - Maria Niemi
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Karin Leander
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Institute of Environmental Medicine, Stockholm, Sweden
| | - Helena Nordenstedt
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Medicine and Infectious Diseases, Danderyd University Hospital, Stockholm, Sweden
| | - Carita Rehn
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Centre of Excellence for Sustainable Health, Karolinska Institutet in Stockholm, Solna, Sweden
| | - Rawlance Ndejjo
- Centre of Excellence for Sustainable Health, Karolinska Institutet in Stockholm, Solna, Sweden
- School of Public Health, Makerere University, Kampala, Uganda
| | - Rhoda Wanyenze
- Centre of Excellence for Sustainable Health, Karolinska Institutet in Stockholm, Solna, Sweden
- School of Public Health, Makerere University, Kampala, Uganda
| | - Olivia Biermann
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Centre of Excellence for Sustainable Health, Karolinska Institutet in Stockholm, Solna, Sweden
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Biermann O, Nordenstam A, Muwonge T, Kabiri L, Ndeezi G, Alfvén T. Sustainable preventive integrated child health care: reflections on the importance of multidisciplinary and multisectoral stakeholder engagement. Glob Health Action 2023; 16:2173853. [PMID: 36762539 PMCID: PMC9930826 DOI: 10.1080/16549716.2023.2173853] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Abstract
Worldwide, 85% of all children who die are under the age of five. A recent scoping review examining the literature from 2000 to 2021 shows the importance of sustainable integrated preventive child health care for improving child health, enhancing the uptake of preventive child health services, and decreasing health-care costs. In 2022, we organised a stakeholder workshop in Uganda to discuss and contextualise the findings of the scoping review. The workshop took place under the umbrella of the Centre of Excellence for Sustainable Health, a virtual collaborative centre co-hosted by Makerere University in Uganda and Karolinska Institutet in Sweden. The workshop convened multidisciplinary and multisectoral stakeholders, including parents, nurses, paediatricians, nutritionists, village health team members, religious leaders, social workers, teachers, lawyers, health and climate researchers, and representatives from the police, the agricultural sector, the Ministry of Health, the World Health Organization, and other international and national non-governmental organisations, among others. We reflect on the importance of multidisciplinary and multisectoral stakeholder engagement, not only in building bridges between research and practice but also in linking sectors and connecting people for sustainable preventive integrated child health care. Though an important step, this workshop was only a first step; over time, relationships must be nurtured, multisectoral systems built and research and policy closely connected. We hope this workshop will not remain a one-off event but becomes an institutionalised effort that sparks action for sustainable preventive integrated child health care in Kampala and beyond, and sustainable health for all.
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Affiliation(s)
- Olivia Biermann
- Department of Global Public Health, Karolinska Institutet, Solna, Sweden,Centre of Excellence for Sustainable Health, Makerere University, Kampala, Uganda,Centre of Excellence for Sustainable Health, Karolinska Institute, Solna, Sweden,CONTACT Olivia Biermann Department of Global Public Health, Karolinska Institutet, Tomtebodavägen 18a, 17177Solna, Sweden
| | - Alma Nordenstam
- Department of Global Public Health, Karolinska Institutet, Solna, Sweden,Centre of Excellence for Sustainable Health, Makerere University, Kampala, Uganda,Centre of Excellence for Sustainable Health, Karolinska Institute, Solna, Sweden
| | - Tonny Muwonge
- School of Public Health, Makerere University, Kampala, Uganda
| | - Lydia Kabiri
- School of Health Sciences, Department of Nursing, Makerere University, Kampala, Uganda
| | - Grace Ndeezi
- Centre of Excellence for Sustainable Health, Makerere University, Kampala, Uganda,Centre of Excellence for Sustainable Health, Karolinska Institute, Solna, Sweden,School of Medicine, Makerere University, Kampala, Uganda
| | - Tobias Alfvén
- Department of Global Public Health, Karolinska Institutet, Solna, Sweden,Centre of Excellence for Sustainable Health, Makerere University, Kampala, Uganda,Centre of Excellence for Sustainable Health, Karolinska Institute, Solna, Sweden,Sachs’ Children and Youth Hospital, Stockholm, Sweden
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Jarde A, Siqueira N, Afaq S, Naz F, Irfan M, Tufail P, Aslam F, Todowede O, Rakhshanda S, Khalid H, Lin Y, Biermann O, Elsony A, Elsey H, Siddiqi N, Siddiqi K. Correction: Addressing TB multimorbidity in policy and practice: An exploratory survey of TB providers in 27 high-TB burden countries. PLOS Glob Public Health 2023; 3:e0002186. [PMID: 37436974 DOI: 10.1371/journal.pgph.0002186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
[This corrects the article DOI: 10.1371/journal.pgph.0001205.].
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Biermann O, Wingfield T, Thapa B, Babajide O, Zeinali Z, Torres I, Abdalla SM, Galea S. Use of big data on the social determinants of TB to find the "missing millions". Int J Tuberc Lung Dis 2022; 26:1194-1196. [PMID: 36447326 PMCID: PMC9728948 DOI: 10.5588/ijtld.22.0080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 08/09/2022] [Indexed: 12/05/2022] Open
Affiliation(s)
- O Biermann
- Department of Global Public Health, Karolinska Institutet, Solna, Sweden
| | - T Wingfield
- Department of Global Public Health, Karolinska Institutet, Solna, Sweden, Departments of International Public Health and Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - B Thapa
- Department of Health Services, Policy and Practice, Brown University, Providence, RI, USA
| | - O Babajide
- Urban Health Collaborative, Drexel University, Philadelphia, PA, USA
| | - Z Zeinali
- Rockefeller Foundation, Boston University 3-D Commission on Determinants, Data, and Decision-making, Boston, MA, USA
| | - I Torres
- Fundación Octaedro, Quito, Ecuador
| | - S M Abdalla
- Boston University School of Public Health, Boston, MA, USA
| | - Sandro Galea
- Boston University School of Public Health, Boston, MA, USA
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Winters M, Biermann O, Bohlin G, Bergman M, Brounéus F, Zeebari Z, Nordenstedt H. Media use and trust during the COVID-19 pandemic: evidence from eight cross-sectional surveys in Sweden. Eur J Public Health 2022; 32:976-981. [PMID: 36223605 DOI: 10.1093/eurpub/ckac145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND While a lot has been written about Sweden's COVID-19 control strategy, less is known about Swedish residents' media use during the pandemic and trust in and perceived agreement among key stakeholders commenting in the media. METHODS Eight online, nationwide surveys were fielded between March and August 2020, during the first wave of the coronavirus pandemic in Sweden, with 8146 responses. Questions were asked on media usage, perceived tone of media, trust in key pandemic stakeholder groups commenting in the media (politicians, journalists, government officials, doctors/healthcare professionals and researchers) and perceived agreement among these key stakeholders about how the pandemic was handled in Sweden. RESULTS Using five or more information sources was associated with increased perceived alarmism in the media. Women and those with tertiary education were more likely to trust key pandemic actors. Trust in doctors/healthcare professionals and researchers remained high over the course of the study, trust in politicians and journalists was relatively low throughout the study period, with a slight increase in April 2020. Trust in key stakeholders was strongly associated with perceived agreement among the key stakeholders. CONCLUSIONS Our results show that trust in stakeholders was strongly associated with perceived consistency of messages from those stakeholders. The inverse also holds: perceived conflicting messages among stakeholders was associated with low trust in them. Taken together, this could point to the importance of building trust before a crisis. Trust-building efforts could be targeted to men and those with lower educational attainment, as they had lower trust in key stakeholders.
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Affiliation(s)
- Maike Winters
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Olivia Biermann
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Gustav Bohlin
- Public & Science (V&A), Stockholm, Sweden.,Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | | | | | - Zangin Zeebari
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.,Department of Economics, Finance and Statistics, Jönköping International Business School, Jönköping, Sweden
| | - Helena Nordenstedt
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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Van't Hoog A, Viney K, Biermann O, Yang B, Leeflang MM, Langendam MW. Symptom- and chest-radiography screening for active pulmonary tuberculosis in HIV-negative adults and adults with unknown HIV status. Cochrane Database Syst Rev 2022; 3:CD010890. [PMID: 35320584 PMCID: PMC9109771 DOI: 10.1002/14651858.cd010890.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Systematic screening in high-burden settings is recommended as a strategy for early detection of pulmonary tuberculosis disease, reducing mortality, morbidity and transmission, and improving equity in access to care. Questioning for symptoms and chest radiography (CXR) have historically been the most widely available tools to screen for tuberculosis disease. Their accuracy is important for the design of tuberculosis screening programmes and determines, in combination with the accuracy of confirmatory diagnostic tests, the yield of a screening programme and the burden on individuals and the health service. OBJECTIVES To assess the sensitivity and specificity of questioning for the presence of one or more tuberculosis symptoms or symptom combinations, CXR, and combinations of these as screening tools for detecting bacteriologically confirmed pulmonary tuberculosis disease in HIV-negative adults and adults with unknown HIV status who are considered eligible for systematic screening for tuberculosis disease. Second, to investigate sources of heterogeneity, especially in relation to regional, epidemiological, and demographic characteristics of the study populations. SEARCH METHODS We searched the MEDLINE, Embase, LILACS, and HTA (Health Technology Assessment) databases using pre-specified search terms and consulted experts for unpublished reports, for the period 1992 to 2018. The search date was 10 December 2018. This search was repeated on 2 July 2021. SELECTION CRITERIA Studies were eligible if participants were screened for tuberculosis disease using symptom questions, or abnormalities on CXR, or both, and were offered confirmatory testing with a reference standard. We included studies if diagnostic two-by-two tables could be generated for one or more index tests, even if not all participants were subjected to a microbacteriological reference standard. We excluded studies evaluating self-reporting of symptoms. DATA COLLECTION AND ANALYSIS We categorized symptom and CXR index tests according to commonly used definitions. We assessed the methodological quality of included studies using the QUADAS-2 instrument. We examined the forest plots and receiver operating characteristic plots visually for heterogeneity. We estimated summary sensitivities and specificities (and 95% confidence intervals (CI)) for each index test using bivariate random-effects methods. We analyzed potential sources of heterogeneity in a hierarchical mixed-model. MAIN RESULTS The electronic database search identified 9473 titles and abstracts. Through expert consultation, we identified 31 reports on national tuberculosis prevalence surveys as eligible (of which eight were already captured in the search of the electronic databases), and we identified 957 potentially relevant articles through reference checking. After removal of duplicates, we assessed 10,415 titles and abstracts, of which we identified 430 (4%) for full text review, whereafter we excluded 364 articles. In total, 66 articles provided data on 59 studies. We assessed the 2 July 2021 search results; seven studies were potentially eligible but would make no material difference to the review findings or grading of the evidence, and were not added in this edition of the review. We judged most studies at high risk of bias in one or more domains, most commonly because of incorporation bias and verification bias. We judged applicability concerns low in more than 80% of studies in all three domains. The three most common symptom index tests, cough for two or more weeks (41 studies), any cough (21 studies), and any tuberculosis symptom (29 studies), showed a summary sensitivity of 42.1% (95% CI 36.6% to 47.7%), 51.3% (95% CI 42.8% to 59.7%), and 70.6% (95% CI 61.7% to 78.2%, all very low-certainty evidence), and a specificity of 94.4% (95% CI 92.6% to 95.8%, high-certainty evidence), 87.6% (95% CI 81.6% to 91.8%, low-certainty evidence), and 65.1% (95% CI 53.3% to 75.4%, low-certainty evidence), respectively. The data on symptom index tests were more heterogenous than those for CXR. The studies on any tuberculosis symptom were the most heterogeneous, but had the lowest number of variables explaining this variation. Symptom index tests also showed regional variation. The summary sensitivity of any CXR abnormality (23 studies) was 94.7% (95% CI 92.2% to 96.4%, very low-certainty evidence) and 84.8% (95% CI 76.7% to 90.4%, low-certainty evidence) for CXR abnormalities suggestive of tuberculosis (19 studies), and specificity was 89.1% (95% CI 85.6% to 91.8%, low-certainty evidence) and 95.6% (95% CI 92.6% to 97.4%, high-certainty evidence), respectively. Sensitivity was more heterogenous than specificity, and could be explained by regional variation. The addition of cough for two or more weeks, whether to any (pulmonary) CXR abnormality or to CXR abnormalities suggestive of tuberculosis, resulted in a summary sensitivity and specificity of 99.2% (95% CI 96.8% to 99.8%) and 84.9% (95% CI 81.2% to 88.1%) (15 studies; certainty of evidence not assessed). AUTHORS' CONCLUSIONS The summary estimates of the symptom and CXR index tests may inform the choice of screening and diagnostic algorithms in any given setting or country where screening for tuberculosis is being implemented. The high sensitivity of CXR index tests, with or without symptom questions in parallel, suggests a high yield of persons with tuberculosis disease. However, additional considerations will determine the design of screening and diagnostic algorithms, such as the availability and accessibility of CXR facilities or the resources to fund them, and the need for more or fewer diagnostic tests to confirm the diagnosis (depending on screening test specificity), which also has resource implications. These review findings should be interpreted with caution due to methodological limitations in the included studies and regional variation in sensitivity and specificity. The sensitivity and specificity of an index test in a specific setting cannot be predicted with great precision due to heterogeneity. This should be borne in mind when planning for and implementing tuberculosis screening programmes.
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Affiliation(s)
- Anja Van't Hoog
- Anja van't Hoog, Health Research & Training Consultancy, Utrecht, Netherlands
| | - Kerri Viney
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- School of Public Health, The University of Sydney, Sydney, Australia
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - Olivia Biermann
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Bada Yang
- Epidemiology and Data Science, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Mariska Mg Leeflang
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Miranda W Langendam
- Epidemiology and Data Science, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
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Dixit K, Biermann O, Rai B, Aryal TP, Mishra G, Teixeira de Siqueira-Filha N, Paudel PR, Pandit RN, Sah MK, Majhi G, Levy J, Rest JV, Gurung SC, Dhital R, Lönnroth K, Squire SB, Caws M, Sidney K, Wingfield T. Barriers and facilitators to accessing tuberculosis care in Nepal: a qualitative study to inform the design of a socioeconomic support intervention. BMJ Open 2021; 11:e049900. [PMID: 34598986 PMCID: PMC8488704 DOI: 10.1136/bmjopen-2021-049900] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 09/10/2021] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE Psychosocial and economic (socioeconomic) barriers, including poverty, stigma and catastrophic costs, impede access to tuberculosis (TB) services in low-income countries. We aimed to characterise the socioeconomic barriers and facilitators of accessing TB services in Nepal to inform the design of a locally appropriate socioeconomic support intervention for TB-affected households. DESIGN From August 2018 to July 2019, we conducted an exploratory qualitative study consisting of semistructured focus group discussions (FGDs) with purposively selected multisectoral stakeholders. The data were managed in NVivo V.12, coded by consensus and analysed thematically. SETTING The study was conducted in four districts, Makwanpur, Chitwan, Dhanusha and Mahottari, which have a high prevalence of poverty and TB. PARTICIPANTS Seven FGDs were conducted with 54 in-country stakeholders, grouped by stakeholders, including people with TB (n=21), community stakeholders (n=13) and multidisciplinary TB healthcare professionals (n=20) from the National TB Programme. RESULTS The perceived socioeconomic barriers to accessing TB services were: inadequate TB knowledge and advocacy; high food and transportation costs; income loss and stigma. The perceived facilitators to accessing TB care and services were: enhanced championing and awareness-raising about TB and TB services; social protection including health insurance; cash, vouchers and/or nutritional allowance to cover food and travel costs; and psychosocial support and counselling integrated with existing adherence counselling from the National TB Programme. CONCLUSION These results suggest that support interventions that integrate TB education, psychosocial counselling and expand on existing cash transfer schemes would be locally appropriate and could address the socioeconomic barriers to accessing and engaging with TB services faced by TB-affected households in Nepal. The findings have been used to inform the design of a socioeconomic support intervention for TB-affected households. The acceptability, feasibility and impact of this intervention on TB-related costs, stigma and TB treatment outcomes, is now being evaluated in a pilot implementation study in Nepal.
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Affiliation(s)
- Kritika Dixit
- Department of Research, Birat Nepal Medical Trust (BNMT), Kathmandu, Nepal
- Department of Global Public Health, WHO Collaborating Centre on Tuberculosis and Social Medicine, Karolinska Institute, Stockholm, Sweden
| | - Olivia Biermann
- Department of Global Public Health, WHO Collaborating Centre on Tuberculosis and Social Medicine, Karolinska Institute, Stockholm, Sweden
| | - Bhola Rai
- Department of Research, Birat Nepal Medical Trust (BNMT), Kathmandu, Nepal
| | - Tara Prasad Aryal
- Department of Research, Birat Nepal Medical Trust (BNMT), Kathmandu, Nepal
| | - Gokul Mishra
- Department of Research, Birat Nepal Medical Trust (BNMT), Kathmandu, Nepal
- Departments of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Noemia Teixeira de Siqueira-Filha
- Departments of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- Department of Health Sciences, University of York, York, UK
| | - Puskar Raj Paudel
- Department of Research, Birat Nepal Medical Trust (BNMT), Kathmandu, Nepal
- KNCV Tuberculosis Foundation, Den Haag, The Netherlands
| | - Ram Narayan Pandit
- Department of Research, Birat Nepal Medical Trust (BNMT), Kathmandu, Nepal
| | - Manoj Kumar Sah
- Department of Research, Birat Nepal Medical Trust (BNMT), Kathmandu, Nepal
| | - Govinda Majhi
- Department of Research, Birat Nepal Medical Trust (BNMT), Kathmandu, Nepal
| | - Jens Levy
- KNCV Tuberculosis Foundation, Den Haag, The Netherlands
| | - Job van Rest
- KNCV Tuberculosis Foundation, Den Haag, The Netherlands
| | - Suman Chandra Gurung
- Department of Research, Birat Nepal Medical Trust (BNMT), Kathmandu, Nepal
- Departments of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Raghu Dhital
- Department of Research, Birat Nepal Medical Trust (BNMT), Kathmandu, Nepal
| | - Knut Lönnroth
- Department of Global Public Health, WHO Collaborating Centre on Tuberculosis and Social Medicine, Karolinska Institute, Stockholm, Sweden
| | - S Bertel Squire
- Departments of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- Tropical and Infectious Disease Unit, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
| | - Maxine Caws
- Department of Research, Birat Nepal Medical Trust (BNMT), Kathmandu, Nepal
- Departments of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Kristi Sidney
- Department of Global Public Health, WHO Collaborating Centre on Tuberculosis and Social Medicine, Karolinska Institute, Stockholm, Sweden
| | - Tom Wingfield
- Department of Global Public Health, WHO Collaborating Centre on Tuberculosis and Social Medicine, Karolinska Institute, Stockholm, Sweden
- Departments of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- Tropical and Infectious Disease Unit, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
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Biermann O, Mwoka M, Ettman CK, Abdalla SM, Shawky S, Ambuko J, Pearson M, Zeinali Z, Galea S, Mberu B, Valladares LM. Data, Social Determinants, and Better Decision-making for Health: the 3-D Commission. J Urban Health 2021; 98:4-14. [PMID: 34414512 PMCID: PMC8376119 DOI: 10.1007/s11524-021-00556-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/07/2021] [Indexed: 12/24/2022]
Abstract
More than a decade after the World Health Organization Commission on the Social Determinants of Health (SDoH), it is becoming widely accepted that social and economic factors, including but not limited to education, energy, income, race, ethnicity, and housing, are important drivers of health in populations. Despite this understanding, in most contexts, social determinants are not central to local, national, or global decision-making. Greater clarity in conceptualizing social determinants, and more specificity in measuring them, can move us forward towards better incorporating social determinants in decision-making for health. In this paper, first, we summarize the evolution of the social framing of health. Second, we describe how the social determinants are conceptualized and contextualized differently at the global, national, and local levels. With this, we seek to demonstrate the importance of analyzing and understanding SDoH relative to the contexts in which they are experienced. Third, we problematize the gap in data across contexts on different dimensions of social determinants and describe data that could be curated to better understand the influence of social determinants at the local and national levels. Fourth, we describe the necessity of using data to understand social determinants and inform decision-making to improve health. Our overall goal is to provide a path for our collective understanding of the foundational causes of health, facilitated by advances in data access and quality, and realized through improved decision-making.
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Affiliation(s)
- Olivia Biermann
- Department of Global Public Health, Karolinska Institutet, Solna, Sweden
- Rockefeller Foundation-Boston University 3-D Commission on Determinants, Data, and Decision-making, Boston, USA
| | - Meggie Mwoka
- Rockefeller Foundation-Boston University 3-D Commission on Determinants, Data, and Decision-making, Boston, USA
| | - Catherine K. Ettman
- Rockefeller Foundation-Boston University 3-D Commission on Determinants, Data, and Decision-making, Boston, USA
- Boston University School of Public Health, Boston, USA
| | - Salma M Abdalla
- Rockefeller Foundation-Boston University 3-D Commission on Determinants, Data, and Decision-making, Boston, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, USA
| | - Sherine Shawky
- Rockefeller Foundation-Boston University 3-D Commission on Determinants, Data, and Decision-making, Boston, USA
- The Social Research Center, The American University in Cairo, Cairo, Egypt
| | - Jane Ambuko
- Rockefeller Foundation-Boston University 3-D Commission on Determinants, Data, and Decision-making, Boston, USA
- University of Nairobi, Nairobi, Kenya
| | - Mark Pearson
- Rockefeller Foundation-Boston University 3-D Commission on Determinants, Data, and Decision-making, Boston, USA
- OECD, Paris, France
| | - Zahra Zeinali
- Rockefeller Foundation-Boston University 3-D Commission on Determinants, Data, and Decision-making, Boston, USA
| | - Sandro Galea
- Rockefeller Foundation-Boston University 3-D Commission on Determinants, Data, and Decision-making, Boston, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, USA
| | - Blessing Mberu
- Rockefeller Foundation-Boston University 3-D Commission on Determinants, Data, and Decision-making, Boston, USA
- African Population and Health Research Center, Nairobi, Kenya
| | - Laura Magaña Valladares
- Rockefeller Foundation-Boston University 3-D Commission on Determinants, Data, and Decision-making, Boston, USA
- Association of Schools and Programs of Public Health (ASPPH), Washington DC, USA
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10
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Mwoka M, Biermann O, Ettman CK, Abdalla SM, Ambuko J, Pearson M, Rashid SF, Zeinali Z, Galea S, Valladares LM, Mberu B. Housing as a Social Determinant of Health: Evidence from Singapore, the UK, and Kenya: the 3-D Commission. J Urban Health 2021; 98:15-30. [PMID: 34480327 PMCID: PMC8415197 DOI: 10.1007/s11524-021-00557-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/07/2021] [Indexed: 10/31/2022]
Abstract
Housing is a paradigmatic example of a social determinant of health, as it influences and is influenced by structural determinants, such as social, macroeconomic, and public policies, politics, education, income, and ethnicity/race, all intersecting to shaping the health and well-being of populations. It can therefore be argued that housing policy is critically linked to health policy. However, the extent to which this linkage is understood and addressed in public policies is limited and highly diverse across and within countries. This analysis seeks to describe the linkages between housing policies and health and well-being using examples from three countries at different levels of the wealth spectrum: Singapore, the UK, and Kenya.We conducted a comparative policy analysis across three country contexts (Singapore, the UK, and Kenya) to document the extent to which housing policies address health and well-being, highlighting commonalities and differences among them. To guide our analysis, we used the United Nations (UN) definition of adequate housing as it offers a broad framework to analyze the impact of housing on health and well-being.The anatomy of housing policies has a strong correlation to the provision of adequate housing across Singapore, the UK, and Kenya, especially for vulnerable groups. The paper demonstrates that contextual factors including population composition (i.e., aging versus youthful), political ideologies, legal frameworks (i.e., welfare versus market-based provision of housing), and presence (or absence) of adequate, quality, timely, reliable, robust data systems for decision-making, which are taken up by stakeholders/state, have strong implications of the type of housing policies developed and implemented, in turn directly and indirectly impacting the overall health and well-being of populations.This analysis demonstrates the value of viewing housing policies as public health policies that could significantly impact the health and well-being of populations, especially vulnerable groups. Moreover, the findings highlight the importance of the Health in All Policies approach to facilitate integrated policy responses to address social determinants of health such as housing. This is more critical than ever, given the context of the global pandemic that has led to worsening overall health and well-being.
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Affiliation(s)
- Meggie Mwoka
- Rockefeller Foundation-Boston University 3-D Commission on Determinants, Data, and Decision-making, Boston, USA
| | - Olivia Biermann
- Rockefeller Foundation-Boston University 3-D Commission on Determinants, Data, and Decision-making, Boston, USA.,Department of Global Public Health, Karolinska Institutet, Solna, Sweden
| | - Catherine K Ettman
- Rockefeller Foundation-Boston University 3-D Commission on Determinants, Data, and Decision-making, Boston, USA.,Boston University School of Public Health, Boston, USA
| | - Salma M Abdalla
- Rockefeller Foundation-Boston University 3-D Commission on Determinants, Data, and Decision-making, Boston, USA. .,Department of Epidemiology, Boston University School of Public Health, Boston, USA.
| | - Jane Ambuko
- Rockefeller Foundation-Boston University 3-D Commission on Determinants, Data, and Decision-making, Boston, USA.,University of Nairobi, Nairobi, Kenya
| | - Mark Pearson
- Rockefeller Foundation-Boston University 3-D Commission on Determinants, Data, and Decision-making, Boston, USA.,OECD, Paris, France
| | - Sabina Faiz Rashid
- Rockefeller Foundation-Boston University 3-D Commission on Determinants, Data, and Decision-making, Boston, USA.,Brac James P Grant School of Public Health, Brac University, Dhaka, Bangladesh
| | - Zahra Zeinali
- Rockefeller Foundation-Boston University 3-D Commission on Determinants, Data, and Decision-making, Boston, USA
| | - Sandro Galea
- Rockefeller Foundation-Boston University 3-D Commission on Determinants, Data, and Decision-making, Boston, USA.,Department of Epidemiology, Boston University School of Public Health, Boston, USA
| | - Laura Magaña Valladares
- Rockefeller Foundation-Boston University 3-D Commission on Determinants, Data, and Decision-making, Boston, USA.,Association of Schools and Programs of Public Health (ASPPH), Washington DC, USA
| | - Blessing Mberu
- Rockefeller Foundation-Boston University 3-D Commission on Determinants, Data, and Decision-making, Boston, USA.,African Population and Health Research Center, Nairobi, Kenya
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11
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Abstract
Food is an important determinant of health, featuring prominently in the Sustainable Development Goals. The term "big data" is seldom used in relation to food, partly because food data are scattered across different sectors. The increasing availability of food-related data presents an opportunity to glean new insights on food and food systems. These insights may enhance the quality of products and services and improve decision-making on optimizing food availability, all to the end of producing better health. Yet, knowledge gaps remain about the unique opportunities and challenges linked to big data on food and their use in decision-making. This scoping review explored the available literature linking food with big data and decision-making, using the following research question: What is the current literature on data about food, and how are these data used in decision-making? We searched PubMed until 29 February 2020 and Embase, Web of Sciences, and the Cochrane Database of Systematic Reviews until 8 March 2020. We included studies written in English and conducted narrative analyses to identify relevant themes from included studies. Sixteen studies fulfilled our eligibility criteria, including big data analyses, modelling studies, and reviews. These studies described the added value of using big data and how evidence from big data had or can be used for decision-making, as well as challenges and opportunities for such use. The majority of the included studies examined the link between food and big data, while hypothesizing of how these insights could inform decision-making, including policies, interventions, programs, and financing. There were only two examples wherein big data on food informed decision-making directly. The review highlights several false dichotomies in how the subject is approached in the literature and the importance of context, both between and within countries, in shaping the availability and types of data that can be used as meaningful evidence to inform decision-making. This review shows the paucity of research around the intersection of food, big data, and decision-making, as well as the potential in using big data on food systems to the end of informing decisions to improve the health of populations. Future research and decision-making around health systems can benefit from examining the full spectrum of perspectives on the subject. Future research and decision-making around health systems can also employ the steadfast embrace of technology, which will potentially reduce disparities in big data availability, to the end of improving the health of populations.
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Affiliation(s)
- Olivia Biermann
- Department of Global Public Health, Karolinska Institutet, Solna, Sweden
- Rockefeller Foundation-Boston University 3-D Commission on Determinants, Data, and Decision-making, Boston, USA
| | - Shaffi Fazaludeen Koya
- Rockefeller Foundation-Boston University 3-D Commission on Determinants, Data, and Decision-making, Boston, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, USA
| | - Claire Corkish
- Rockefeller Foundation-Boston University 3-D Commission on Determinants, Data, and Decision-making, Boston, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, USA
| | - Salma M Abdalla
- Rockefeller Foundation-Boston University 3-D Commission on Determinants, Data, and Decision-making, Boston, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, USA
| | - Sandro Galea
- Rockefeller Foundation-Boston University 3-D Commission on Determinants, Data, and Decision-making, Boston, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, USA
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Biermann O, Tran PB, Forse RJ, Vo LNQ, Codlin AJ, Viney K, Caws M, Lönnroth K. Capitalizing on facilitators and addressing barriers when implementing active tuberculosis case-finding in six districts of Ho Chi Minh City, Vietnam: a qualitative study with key stakeholders. Implement Sci 2021; 16:54. [PMID: 34011353 PMCID: PMC8135167 DOI: 10.1186/s13012-021-01124-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 05/03/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Vietnam has a high burden of undetected tuberculosis (TB). The Vietnamese National TB Strategic Plan highlights active case-finding (ACF) as one strategy to find people with TB who are currently unreached by the existing government health services. The IMPACT TB (Implementing proven community-based active TB case-finding intervention) project was implemented across six districts of Ho Chi Minh City, 2017-2019. We aimed to explore the facilitators and barriers for ACF implementation during the IMPACT TB project to understand how and why the intervention achieved high yields. METHODS This was an exploratory qualitative study based on 39 semi-structured key-informant interviews with TB patients who were diagnosed through ACF, employees and volunteers who implemented ACF, and leaders from district, national, or international institutions and organizations in Vietnam. Thematic analysis was applied, using an implementation science framework by Grol and Wensing. RESULTS We generated three main themes: (1) the studied ACF model used in Vietnam provided a conducive social and organizational context for ACF implementation with areas for improvement, including communication and awareness-raising, preparation and logistics, data systems and processes, and incentives; (2) employees and volunteers capitalized on their strengths to facilitate ACF implementation, e.g., experience, skills, and communication; and (3) employees and volunteers were in a position to address patient-level barriers to ACF implementation, e.g., stigma, discrimination, and mistrust. These themes covered a variety of facilitators and barriers, which we divided into 17 categories. All categories were mentioned by employees and volunteers, except the category of having a network that facilitates ACF implementation, which was only mentioned by volunteers. This study also highlighted examples and ideas of how to address facilitators and barriers. CONCLUSIONS IMPACT TB provided a favorable social and organizational context for ACF implementation. Individual employees and volunteers still determined the success of the project, as they had to be able to capitalize on their own strengths and address patient-level barriers. Volunteers especially used their networks to facilitate ACF. Knowledge of both facilitators and barriers, and how to address them can inform the planning and implementation ACF in Vietnam and similar contexts across low- and middle-income countries worldwide.
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Affiliation(s)
- Olivia Biermann
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
| | - Phuong Bich Tran
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Rachel Jeanette Forse
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Friends for International Tuberculosis Relief, Ho Chi Minh City, Vietnam
| | | | | | - Kerri Viney
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Research School of Population Health, College of Health and Medicine, Australian National University, Canberra, Australia
| | - Maxine Caws
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Nepal
| | - Knut Lönnroth
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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13
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Biermann O, Dixit K, Rai B, Caws M, Lönnroth K, Viney K. Building on facilitators and overcoming barriers to implement active tuberculosis case-finding in Nepal, experiences of community health workers and people with tuberculosis. BMC Health Serv Res 2021; 21:295. [PMID: 33794878 PMCID: PMC8015737 DOI: 10.1186/s12913-021-06290-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 03/16/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Nepal has a high burden of undetected tuberculosis (TB). In line with the World Health Organization's End TB Strategy, the National TB Programme promotes active case-finding (ACF) as one strategy to find people with TB who are unreached by existing health services. The IMPACT TB (Implementing proven community-based active TB case-finding intervention) project was implemented in four districts in Nepal, generating a substantial yield of previously undetected TB. We aimed to identify the facilitators and barriers linked to the implementation of ACF within IMPACT TB, as well as how those facilitators and barriers have been or could be addressed. METHODS This was an exploratory qualitative study based on 17 semi-structured key-informant interviews with people with TB who were identified through ACF, and community health workers who had implemented ACF. Thematic analysis was applied in NVivo 11, using an implementation science framework developed by Grol and Wensing to classify the data. RESULTS We generated five main themes from the data: (1) ACF addressed the social determinants of TB by providing timely access to free healthcare, (2) knowledge and awareness about TB among people with TB, communities and community health workers were the 'oil' in the ACF 'machine', (3) trust in community health workers was fundamental for implementing ACF, (4) community engagement and support had a powerful influence on ACF implementation and (5) improved working conditions and enhanced collaboration with key stakeholders could further facilitate ACF. These themes covered a variety of facilitators and barriers, which we divided into 22 categories cutting across five framework levels: innovation, individual professional, patient, social context and organizational context. CONCLUSIONS This study provides new insights into facilitators and barriers for the implementation of ACF in Nepal and emphasizes the importance of addressing the social determinants of TB. The main themes reflect key ingredients which are required for successful ACF implementation, while the absence of these factors may convert them from facilitators into barriers for ACF. As this study outlined "how-to" strategies for ACF implementation, the findings can furthermore inform the planning and implementation of ACF in Nepal and similar contexts in low- and middle-income countries.
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Affiliation(s)
- Olivia Biermann
- Department of Global Public Health, WHO Collaborating Centre on Tuberculosis and Social Medicine, Karolinska Institutet, Tomtebodavägen 18a, 17177, Stockholm, Sweden.
| | - Kritika Dixit
- Department of Global Public Health, WHO Collaborating Centre on Tuberculosis and Social Medicine, Karolinska Institutet, Tomtebodavägen 18a, 17177, Stockholm, Sweden.,Birat Nepal Medical Trust, Lazimpat, Kathmandu, Nepal
| | - Bhola Rai
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Nepal
| | - Maxine Caws
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Nepal.,Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Pl, Liverpool, L3 5QA, UK
| | - Knut Lönnroth
- Department of Global Public Health, WHO Collaborating Centre on Tuberculosis and Social Medicine, Karolinska Institutet, Tomtebodavägen 18a, 17177, Stockholm, Sweden
| | - Kerri Viney
- Department of Global Public Health, WHO Collaborating Centre on Tuberculosis and Social Medicine, Karolinska Institutet, Tomtebodavägen 18a, 17177, Stockholm, Sweden.,Research School of Population Health, College of Health and Medicine, Australian National University, Canberra, Australia
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14
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Biermann O, Klüppelberg R, Lönnroth K, Viney K, Caws M, Atkins S. 'A double-edged sword': Perceived benefits and harms of active case-finding for people with presumptive tuberculosis and communities-A qualitative study based on expert interviews. PLoS One 2021; 16:e0247568. [PMID: 33705422 PMCID: PMC7951804 DOI: 10.1371/journal.pone.0247568] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 02/09/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Active case-finding (ACF), also referred to as community-based tuberculosis screening, is a component of the World Health Organization's End TB Strategy. ACF has potential benefits but also harms, which need to be carefully assessed when developing and implementing ACF policies. While empirical evidence on the benefits of ACF is still weak, evidence on the harms is even weaker. This study aimed to explore experts' views on the benefits and harms of ACF for people with presumptive TB and communities. METHODS This was an exploratory study. Semi-structured interviews were conducted with a purposive sample of 39 experts from international, non-governmental/non-profit organizations, funders, government institutions, international societies, think tanks, universities and research institutions worldwide. Framework analysis was applied. RESULTS Findings elaborated perceived benefits of ACF, including reaching vulnerable populations, reducing patient costs, helping raise awareness for tuberculosis among individuals and engaging communities, and reducing tuberculosis transmission. Perceived harms included increasing stigma and discrimination, causing false-positive diagnoses, as well as triggering other unintended consequences related to screening for tuberculosis patients, such as deportation of migrants once confirmed to have tuberculosis. Most of the perceived benefits of ACF could be linked to its objective of finding and treating persons with tuberculosis early (theme 1), while ACF was also perceived as a "double-edged sword" and could cause harms, if inappropriately designed and implemented (theme 2). The analysis underlined the importance of considering the benefits and harms of ACF throughout the screening pathway. The study provides new insights into the perceived benefits and harms of ACF from the perspectives of experts in the field. CONCLUSION This study highlights gaps in the evidence base surrounding ACF and can stimulate further research, debate and analysis regarding the benefits and harms of ACF to inform contextual optimization of design and implementation of ACF strategies.
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Affiliation(s)
- Olivia Biermann
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Raina Klüppelberg
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Knut Lönnroth
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Kerri Viney
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Research School of Population Health, College of Health and Medicine, Australian National University, Canberra, Australia
| | - Maxine Caws
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Nepal
| | - Salla Atkins
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- New Social Research and Global Health and Development, Faculty of Social Sciences, Tampere University, Tampere, Finland
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15
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Pokhrel D, Bhattarai S, Emgård M, von Schickfus M, Forsberg BC, Biermann O. Acceptability and feasibility of using vaginal menstrual cups among schoolgirls in rural Nepal: a qualitative pilot study. Reprod Health 2021; 18:20. [PMID: 33487171 PMCID: PMC7831234 DOI: 10.1186/s12978-020-01036-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 11/02/2020] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Menstrual hygiene management can be challenging in low-income settings and among school-aged girls due to traditional beliefs, lack of knowledge and information on best hygienic practices, and limited access to appropriate and affordable menstrual hygiene products. An alternative method for menstrual hygiene management, instead of sanitary pads or tampons, is the vaginal menstrual cup. As evidence on the use of menstrual cups is relatively limited, this study aimed to explore the acceptability and feasibility of using vaginal menstrual cups among school-aged girls in Thokarpa, Sindupalchowk, Nepal. METHODS This is an exploratory study based on four focus group discussions with a purposive sample of 28 schoolgirls between 13 and 19 years of age who were provided with vaginal menstrual cups in Thokarpa, Sindupalchowk, Nepal. The data were collected between February and March 2019, i.e. approximately three months after the distribution of the menstrual cup. Participants were included in the study if they had started their menstruation and never given birth. Conventional content analysis was applied. RESULTS Most participants perceived the menstrual cup positively. Not missing a single class in school due to problems related to menstrual hygiene management was described as a major benefit. The participants found using the menstrual cup easy and convenient, and described economic and environmental advantages of using it. Cleaning the menstrual cup did not cause any problems, according to the participants. Discomforts mentioned by the participants were: pain when inserting the menstrual cup, feeling the menstrual cup sticking out of the vagina, feeling a constant urge to urinate and leakage. Concerns were related to the size, shape and texture of the menstrual cup, and that it may "get stuck" in the vagina, while relatives were said to be concerned about the use of the menstrual cup leading to reduced fertility or losing virginity. CONCLUSION The use of vaginal menstrual cups for menstrual hygiene management among schoolgirls in Thokarpa, Sindupalchowk, Nepal, appears feasible and acceptable, as it involves practical, economic and environmental advantages. However, the scale-up of menstrual cups will require resolving described concerns and discomforts and fostering peer and family support.
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Affiliation(s)
| | | | - Malin Emgård
- Linköping University Hospital, Linköping, Sweden.,Foundation Human Nature, Nidda, Germany
| | - Michael von Schickfus
- Linköping University Hospital, Linköping, Sweden.,Foundation Human Nature, Nidda, Germany
| | - Birger C Forsberg
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Olivia Biermann
- Foundation Human Nature, Nidda, Germany. .,Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
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16
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Biermann O, Tran PB, Viney K, Caws M, Lönnroth K, Sidney Annerstedt K. Active case-finding policy development, implementation and scale-up in high-burden countries: A mixed-methods survey with National Tuberculosis Programme managers and document review. PLoS One 2020; 15:e0240696. [PMID: 33112890 PMCID: PMC7592767 DOI: 10.1371/journal.pone.0240696] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 10/01/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The World Health Organization (WHO) stresses the importance of active case-finding (ACF) for early detection of tuberculosis (TB), especially in the 30 high-burden countries that account for almost 90% of cases globally. OBJECTIVE To describe the attitudes of National TB Programme (NTP) managers related to ACF policy development, implementation and scale-up in the 30 high-burden countries, and to review national TB strategic plans. METHODS This was a mixed-methods study with an embedded design: A cross-sectional survey with NTP managers yielded quantitative and qualitative data. A review of national TB strategic plans complemented the results. All data were analyzed in parallel and merged in the interpretation of the findings. RESULTS 23 of the 30 NTP managers (77%) participated in the survey and 22 (73%) national TB strategic plans were reviewed. NTP managers considered managers in districts and regions key stakeholders for both ACF policy development and implementation. Different types of evidence were used to inform ACF policy, while there was a particular demand for local evidence. The NSPs reflected the NTP managers' unanimous agreement on the need for ACF scale-up, but not all included explicit aims and targets related to ACF. The NTP managers recognized that ACF may decrease health systems costs in the long-term, while acknowledging the risk for increased health system costs in the short-term. About 90% of the NTP managers declared that financial and human resources were currently lacking, while they also elaborated on strategies to overcome resource constraints. CONCLUSION NTP managers stated that ACF should be scaled up but reported resource constraints. Strategies to increase resources exist but may not yet have been fully implemented, e.g. generating local evidence including from operational research for advocacy. Managers in districts and regions were identified as key stakeholders whose involvement could help improve ACF policy development, implementation and scale-up.
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Affiliation(s)
- Olivia Biermann
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Phuong Bich Tran
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Kerri Viney
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Research School of Population Health, College of Health and Medicine, Australian National University, Canberra, Australia
| | - Maxine Caws
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Nepal
| | - Knut Lönnroth
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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17
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Bekker M, Ivankovic D, Biermann O. Early lessons from COVID-19 response and shifts in authority: public trust, policy legitimacy and political inclusion. Eur J Public Health 2020; 30:854-855. [PMID: 33020828 PMCID: PMC7665464 DOI: 10.1093/eurpub/ckaa181] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Marleen Bekker
- EUPHA Public Health Policy and Politics Section, EUPHA-PHMR, PO Box 1568, 3500 BN Utrecht, Netherlands
| | - Damir Ivankovic
- EUPHA Public Health Policy and Politics Section, EUPHA-PHMR, PO Box 1568, 3500 BN Utrecht, Netherlands
| | - Olivia Biermann
- EUPHA Public Health Policy and Politics Section, EUPHA-PHMR, PO Box 1568, 3500 BN Utrecht, Netherlands.,Department of Global Public Health, Karolinska Institutet, Tomtebodavagen 18a, 17177, Stockholm, Sweden
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18
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Scarlett J, Forsberg BC, Biermann O, Kuchenmüller T, El-Khatib Z. Indicators to evaluate organisational knowledge brokers: a scoping review. Health Res Policy Syst 2020; 18:93. [PMID: 32831095 PMCID: PMC7444249 DOI: 10.1186/s12961-020-00607-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 07/23/2020] [Indexed: 01/03/2023] Open
Abstract
Background Knowledge translation (KT) is currently endorsed by global health policy actors as a means to improve outcomes by institutionalising evidence-informed policy-making. Organisational knowledge brokers, comprised of researchers, policy-makers and other stakeholders, are increasingly being used to undertake and promote KT at all levels of health policy-making, though few resources exist to guide the evaluation of these efforts. Using a scoping review methodology, we identified, synthesised and assessed indicators that have been used to evaluate KT infrastructure and capacity-building activities in a health policy context in order to inform the evaluation of organisational knowledge brokers. Methods A scoping review methodology was used. This included the search of Medline, Global Health and the WHO Library databases for studies regarding the evaluation of KT infrastructure and capacity-building activities between health research and policy, published in English from 2005 to 2016. Data on study characteristics, outputs and outcomes measured, related indicators, mode of verification, duration and/or frequency of collection, indicator methods, KT model, and targeted capacity level were extracted and charted for analysis. Results A total of 1073 unique articles were obtained and 176 articles were qualified to be screened in full-text; 32 articles were included in the analysis. Of a total 213 indicators extracted, we identified 174 (174/213; 81.7%) indicators to evaluate the KT infrastructure and capacity-building that have been developed using methods beyond expert opinion. Four validated instruments were identified. The 174 indicators are presented in 8 domains based on an adaptation of the domains of the Lavis et al. framework of linking research to action – general climate, production of research, push efforts, pull efforts, exchange efforts, integrated efforts, evaluation and capacity-building. Conclusion This review presents a total of 174 method-based indicators to evaluate KT infrastructure and capacity-building. The presented indicators can be used or adapted globally by organisational knowledge brokers and other stakeholders in their monitoring and evaluation work.
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Affiliation(s)
- Julia Scarlett
- Department of Global Public Health, Karolinska Institutet, Tomtebodavägen 18a, SE-171 77, Stockholm, Sweden
| | - Birger C Forsberg
- Department of Global Public Health, Karolinska Institutet, Tomtebodavägen 18a, SE-171 77, Stockholm, Sweden.,Region Stockholm, Hantverkargatan 11B, 112 21, Stockholm, Sweden
| | - Olivia Biermann
- Department of Global Public Health, Karolinska Institutet, Tomtebodavägen 18a, SE-171 77, Stockholm, Sweden
| | - Tanja Kuchenmüller
- World Health Organization Regional Office for Europe, UN City, Marmorvej 51, DK-2100, Copenhagen Ø, Denmark
| | - Ziad El-Khatib
- Department of Global Public Health, Karolinska Institutet, Tomtebodavägen 18a, SE-171 77, Stockholm, Sweden. .,World Health Programme, Université du Québec en Abitibi-Témiscamingue (UQAT), 445 Boulevard de l'Université, Rouyn-Noranda, QC, J9X 5E4, Canada.
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Dixit K, Rai B, Prasad Aryal T, Mishra G, Teixeira de Siqueira-Filha N, Raj Paudel P, Levy JW, van Rest J, Chandra Gurung S, Dhital R, Biermann O, Viney K, Lonnroth K, Squire SB, Caws M, Wingfield T. Research protocol for a mixed-methods study to characterise and address the socioeconomic impact of accessing TB diagnosis and care in Nepal. Wellcome Open Res 2020; 5:19. [PMID: 32964135 PMCID: PMC7489278 DOI: 10.12688/wellcomeopenres.15677.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2020] [Indexed: 12/28/2022] Open
Abstract
Background: WHO's 2015 End TB Strategy advocates social and economic (socioeconomic) support for TB-affected households to improve TB control. However, evidence concerning socioeconomic support for TB-affected households remains limited, especially in low-income countries. Protocol: This mixed-methods study in Nepal will: evaluate the socioeconomic impact of accessing TB diagnosis and care (Project 1); and create a shortlist of feasible, locally-appropriate interventions to mitigate this impact (Project 2). The study will be conducted in the Chitwan, Mahottari, Makawanpur, and Dhanusha districts of Nepal, which have frequent TB and poverty. The study population will include: approximately 200 people with TB (Cases) starting TB treatment with Nepal's National TB Program and 100 randomly-selected people without TB (Controls) in the same sites (Project 1); and approximately 40 key in-country stakeholders from Nepal including people with TB, community leaders, and TB healthcare professionals (Project 2). During Project 1, visits will be made to people with TB's households during months 3 and 6 of TB treatment, and a single visit made to Control households. During visits, participants will be asked about: TB-related costs (if receiving treatment), food insecurity, stigma; TB-related knowledge; household poverty level; social capital; and quality of life. During Project 2, stakeholders will be invited to participate in: a survey and focus group discussion (FGD) to characterise socioeconomic impact, barriers and facilitators to accessing and engaging with TB care in Nepal; and a one-day workshop to review FGD findings and suggest interventions to mitigate the barriers identified. Ethics and dissemination: The study has received ethical approval. Results will be disseminated through scientific meetings, open access publications, and a national workshop in Nepal. Conclusions: This research will strengthen understanding of the socioeconomic impact of TB in Nepal and generate a shortlist of feasible and locally-appropriate socioeconomic interventions for TB-affected households for trial evaluation.
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Affiliation(s)
- Kritika Dixit
- Birat Nepal Medical Trust, Lazimpat Road, Lazimpat, Ward No 2, Box 20564, Kathmandu, Nepal
- Social medicine, Infectious diseases, and Migration (SIM) Group, Department of Public Health Sciences, Karolinska Institute, Solnavägen 1, 171 77 Solna, Stockholm, Sweden
| | - Bhola Rai
- Birat Nepal Medical Trust, Lazimpat Road, Lazimpat, Ward No 2, Box 20564, Kathmandu, Nepal
| | - Tara Prasad Aryal
- Birat Nepal Medical Trust, Lazimpat Road, Lazimpat, Ward No 2, Box 20564, Kathmandu, Nepal
| | - Gokul Mishra
- Birat Nepal Medical Trust, Lazimpat Road, Lazimpat, Ward No 2, Box 20564, Kathmandu, Nepal
| | - Noemia Teixeira de Siqueira-Filha
- Departments of International Public Health and Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Puskar Raj Paudel
- KNCV Tuberculosis Foundation, Postbus 146, 2501 CC Den Haag, The Netherlands
| | - Jens W. Levy
- KNCV Tuberculosis Foundation, Postbus 146, 2501 CC Den Haag, The Netherlands
| | - Job van Rest
- KNCV Tuberculosis Foundation, Postbus 146, 2501 CC Den Haag, The Netherlands
| | - Suman Chandra Gurung
- Birat Nepal Medical Trust, Lazimpat Road, Lazimpat, Ward No 2, Box 20564, Kathmandu, Nepal
- Departments of International Public Health and Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Raghu Dhital
- Birat Nepal Medical Trust, Lazimpat Road, Lazimpat, Ward No 2, Box 20564, Kathmandu, Nepal
| | - Olivia Biermann
- Social medicine, Infectious diseases, and Migration (SIM) Group, Department of Public Health Sciences, Karolinska Institute, Solnavägen 1, 171 77 Solna, Stockholm, Sweden
| | - Kerri Viney
- Social medicine, Infectious diseases, and Migration (SIM) Group, Department of Public Health Sciences, Karolinska Institute, Solnavägen 1, 171 77 Solna, Stockholm, Sweden
| | - Knut Lonnroth
- Social medicine, Infectious diseases, and Migration (SIM) Group, Department of Public Health Sciences, Karolinska Institute, Solnavägen 1, 171 77 Solna, Stockholm, Sweden
| | - S Bertel Squire
- Departments of International Public Health and Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
- Tropical and Infectious Disease Unit, Liverpool University Hospitals NHS Foundation Trust, Prescot Street, Liverpool, L7 8XP, UK
| | - Maxine Caws
- Birat Nepal Medical Trust, Lazimpat Road, Lazimpat, Ward No 2, Box 20564, Kathmandu, Nepal
- Departments of International Public Health and Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Tom Wingfield
- Social medicine, Infectious diseases, and Migration (SIM) Group, Department of Public Health Sciences, Karolinska Institute, Solnavägen 1, 171 77 Solna, Stockholm, Sweden
- Departments of International Public Health and Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
- Tropical and Infectious Disease Unit, Liverpool University Hospitals NHS Foundation Trust, Prescot Street, Liverpool, L7 8XP, UK
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Biermann O, Atkins S, Lönnroth K, Caws M, Viney K. 'Power plays plus push': experts' insights into the development and implementation of active tuberculosis case-finding policies globally, a qualitative study. BMJ Open 2020; 10:e036285. [PMID: 32499270 PMCID: PMC7282330 DOI: 10.1136/bmjopen-2019-036285] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 03/12/2020] [Accepted: 05/11/2020] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To explore experts' views on factors influencing national and global active case-finding (ACF) policy development and implementation, and the use of evidence in these processes. DESIGN This is an exploratory study based on semistructured expert interviews. Framework analysis was applied. PARTICIPANTS The study involved a purposive sample of 39 experts from international, non-governmental and non-profit organisations, funders, government institutions, international societies, think tanks, universities and research institutions worldwide. RESULTS This study highlighted the perceived need among experts for different types of evidence for ACF policy development and implementation, and for stakeholder engagement including researchers and policymakers to foster evidence use. Interviewees stressed the influence of government, donor and non-governmental stakeholders in ACF policy development. Such key stakeholders also influence ACF policy implementation, in addition to available systems and processes in a given health system, and implementers' motivation and incentives. According to the interviewees, the World Health Organization (WHO) guidelines for systematic screening face the innate challenge of providing guidance to countries across the broad area of ACF in terms of target groups, settings and screening algorithms. The guidelines could be improved by focusing on what should be done rather than what can be done in ACF, and by providing howto examples. Leadership, integration into health systems and long-term financing are key for ACF to be sustainable. CONCLUSIONS We provide new insights into ACF policy processes globally, particularly regarding facilitators for and barriers to ACF policy development, evidence need and use, and donor organisations' influence. According to expert participants, national and global ACF policy development and implementation can be improved by broadening stakeholder engagement. Meanwhile, using diverse evidence to inform ACF policy development and implementation could mitigate the 'power plays plus push' that might otherwise disrupt and mislead these policy processes.
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Affiliation(s)
- Olivia Biermann
- Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Salla Atkins
- Global Public Health, Karolinska Institutet, Stockholm, Sweden
- New Social Research and Global Health and Development, Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Knut Lönnroth
- Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Maxine Caws
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- Birat Nepal Medical Trust, Kathmandu, Nepal
| | - Kerri Viney
- Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Research School of Population Health, College of Health and Medicine, Australian National University, Canberra, New South Wales, Australia
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Tran PB, Hensing G, Wingfield T, Atkins S, Sidney Annerstedt K, Kazibwe J, Tomeny E, Biermann O, Thorpe J, Forse R, Lönnroth K. Income security during public health emergencies: the COVID-19 poverty trap in Vietnam. BMJ Glob Health 2020; 5:e002504. [PMID: 32540965 PMCID: PMC7299029 DOI: 10.1136/bmjgh-2020-002504] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/23/2020] [Accepted: 04/24/2020] [Indexed: 11/06/2022] Open
Affiliation(s)
- Phuong Bich Tran
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerpen, Belgium
| | - Gunnel Hensing
- School of Public Health and Community Medicine, Institute of Medicine, the Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden
| | - Tom Wingfield
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Salla Atkins
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- New Social Research and Faculty of Social Sciences, Tampere University, Tampere, Finland
| | | | - Joseph Kazibwe
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK
| | - Ewan Tomeny
- Centre for Applied Health Research & Delivery, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Olivia Biermann
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Jennifer Thorpe
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Rachel Forse
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- TB Programs, Friends for International TB Relief, Ho Chi Minh City, Viet Nam
| | - Knut Lönnroth
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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Dixit K, Rai B, Prasad Aryal T, Mishra G, Teixeira de Siqueira-Filha N, Raj Paudel P, Levy JW, van Rest J, Chandra Gurung S, Dhital R, Biermann O, Viney K, Lonnroth K, Squire SB, Caws M, Wingfield T. Research protocol for a mixed-methods study to characterise and address the socioeconomic impact of accessing TB diagnosis and care in Nepal. Wellcome Open Res 2020; 5:19. [PMID: 32964135 PMCID: PMC7489278 DOI: 10.12688/wellcomeopenres.15677.1] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2020] [Indexed: 03/30/2024] Open
Abstract
Background: WHO's 2015 End TB Strategy advocates social and economic (socioeconomic) support for TB-affected households to improve TB control. However, evidence concerning socioeconomic support for TB-affected households remains limited, especially in low-income countries. Protocol: This mixed-methods study in Nepal will: evaluate the socioeconomic impact of accessing TB diagnosis and care (Project 1); and create a shortlist of feasible, locally-appropriate interventions to mitigate this impact (Project 2). The study will be conducted in the Chitwan, Mahottari, Makawanpur, and Dhanusha districts of Nepal, which have frequent TB and poverty. The study population will include: approximately 200 people with TB (Cases) starting TB treatment with Nepal's National TB Program and 100 randomly-selected people without TB (Controls) in the same sites (Project 1); and approximately 40 key in-country stakeholders from Nepal including people with TB, community leaders, and TB healthcare professionals (Project 2). During Project 1, visits will be made to people with TB's households during months 3 and 6 of TB treatment, and a single visit made to Control households. During visits, participants will be asked about: TB-related costs (if receiving treatment), food insecurity, stigma; TB-related knowledge; household poverty level; social capital; and quality of life. During Project 2, stakeholders will be invited to participate in: a survey and focus group discussion (FGD) to characterise socioeconomic impact, barriers and facilitators to accessing and engaging with TB care in Nepal; and a one-day workshop to review FGD findings and suggest interventions to mitigate the barriers identified. Ethics and dissemination: The study has received ethical approval. Results will be disseminated through scientific meetings, open access publications, and a national workshop in Nepal. Conclusions: This research will strengthen understanding of the socioeconomic impact of TB in Nepal and generate a shortlist of feasible and locally-appropriate socioeconomic interventions for TB-affected households for trial evaluation.
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Affiliation(s)
- Kritika Dixit
- Birat Nepal Medical Trust, Lazimpat Road, Lazimpat, Ward No 2, Box 20564, Kathmandu, Nepal
- Social medicine, Infectious diseases, and Migration (SIM) Group, Department of Public Health Sciences, Karolinska Institute, Solnavägen 1, 171 77 Solna, Stockholm, Sweden
| | - Bhola Rai
- Birat Nepal Medical Trust, Lazimpat Road, Lazimpat, Ward No 2, Box 20564, Kathmandu, Nepal
| | - Tara Prasad Aryal
- Birat Nepal Medical Trust, Lazimpat Road, Lazimpat, Ward No 2, Box 20564, Kathmandu, Nepal
| | - Gokul Mishra
- Birat Nepal Medical Trust, Lazimpat Road, Lazimpat, Ward No 2, Box 20564, Kathmandu, Nepal
| | - Noemia Teixeira de Siqueira-Filha
- Departments of International Public Health and Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Puskar Raj Paudel
- KNCV Tuberculosis Foundation, Postbus 146, 2501 CC Den Haag, The Netherlands
| | - Jens W. Levy
- KNCV Tuberculosis Foundation, Postbus 146, 2501 CC Den Haag, The Netherlands
| | - Job van Rest
- KNCV Tuberculosis Foundation, Postbus 146, 2501 CC Den Haag, The Netherlands
| | - Suman Chandra Gurung
- Birat Nepal Medical Trust, Lazimpat Road, Lazimpat, Ward No 2, Box 20564, Kathmandu, Nepal
- Departments of International Public Health and Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Raghu Dhital
- Birat Nepal Medical Trust, Lazimpat Road, Lazimpat, Ward No 2, Box 20564, Kathmandu, Nepal
| | - Olivia Biermann
- Social medicine, Infectious diseases, and Migration (SIM) Group, Department of Public Health Sciences, Karolinska Institute, Solnavägen 1, 171 77 Solna, Stockholm, Sweden
| | - Kerri Viney
- Social medicine, Infectious diseases, and Migration (SIM) Group, Department of Public Health Sciences, Karolinska Institute, Solnavägen 1, 171 77 Solna, Stockholm, Sweden
| | - Knut Lonnroth
- Social medicine, Infectious diseases, and Migration (SIM) Group, Department of Public Health Sciences, Karolinska Institute, Solnavägen 1, 171 77 Solna, Stockholm, Sweden
| | - S Bertel Squire
- Departments of International Public Health and Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
- Tropical and Infectious Disease Unit, Liverpool University Hospitals NHS Foundation Trust, Prescot Street, Liverpool, L7 8XP, UK
| | - Maxine Caws
- Birat Nepal Medical Trust, Lazimpat Road, Lazimpat, Ward No 2, Box 20564, Kathmandu, Nepal
- Departments of International Public Health and Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Tom Wingfield
- Social medicine, Infectious diseases, and Migration (SIM) Group, Department of Public Health Sciences, Karolinska Institute, Solnavägen 1, 171 77 Solna, Stockholm, Sweden
- Departments of International Public Health and Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
- Tropical and Infectious Disease Unit, Liverpool University Hospitals NHS Foundation Trust, Prescot Street, Liverpool, L7 8XP, UK
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Biermann O, Lönnroth K, Caws M, Viney K. Factors influencing active tuberculosis case-finding policy development and implementation: a scoping review. BMJ Open 2019; 9:e031284. [PMID: 31831535 PMCID: PMC6924749 DOI: 10.1136/bmjopen-2019-031284] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 11/04/2019] [Accepted: 11/20/2019] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVE To explore antecedents, components and influencing factors on active case-finding (ACF) policy development and implementation. DESIGN Scoping review, searching MEDLINE, Web of Science, the Cochrane Database of Systematic Reviews and the World Health Organization (WHO) Library from January 1968 to January 2018. We excluded studies focusing on latent tuberculosis (TB) infection, passive case-finding, childhood TB and studies about effectiveness, yield, accuracy and impact without descriptions of how this evidence has/could influence ACF policy or implementation. We included any type of study written in English, and conducted frequency and thematic analyses. RESULTS Seventy-three articles fulfilled our eligibility criteria. Most (67%) were published after 2010. The studies were conducted in all WHO regions, but primarily in Africa (22%), Europe (23%) and the Western-Pacific region (12%). Forty-one percent of the studies were classified as quantitative, followed by reviews (22%) and qualitative studies (12%). Most articles focused on ACF for tuberculosis contacts (25%) or migrants (32%). Fourteen percent of the articles described community-based screening of high-risk populations. Fifty-nine percent of studies reported influencing factors for ACF implementation; mostly linked to the health system (eg, resources) and the community/individual (eg, social determinants of health). Only two articles highlighted factors influencing ACF policy development (eg, politics). Six articles described WHO's ACF-related recommendations as important antecedent for ACF. Key components of successful ACF implementation include health system capacity, mechanisms for integration, education and collaboration for ACF. CONCLUSION We identified some main themes regarding the antecedents, components and influencing factors for ACF policy development and implementation. While we know much about facilitators and barriers for ACF policy implementation, we know less about how to strengthen those facilitators and how to overcome those barriers. A major knowledge gap remains when it comes to understanding which contextual factors influence ACF policy development. Research is required to understand, inform and improve ACF policy development and implementation.
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Affiliation(s)
- Olivia Biermann
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Knut Lönnroth
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Maxine Caws
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
- Birat Nepal Medical Trust, Kathmandu, Lazimpat, Nepal
| | - Kerri Viney
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Research School of Population Health, College of Health and Medicine, Australian National University, Canberra, Australian Capital Territory, Australia
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Oh KH, Rahevar K, Nishikiori N, Viney K, Choi H, Biermann O, Kim HJ, Nou C, Kim S, Zhu G, Zhang H, Xu C, Bounmala S, Senchanthixay M, Purevdorj E, Khaltar UO, Paguirigan R, Amoguis H, Xuan Phu V, Khang DX. Action towards Universal Health Coverage and Social Protection for Tuberculosis Care and Prevention: Workshop on the End TB Strategy Pillar 2 in the Western Pacific Region 2017. Trop Med Infect Dis 2018; 4:tropicalmed4010003. [PMID: 30586903 PMCID: PMC6473827 DOI: 10.3390/tropicalmed4010003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 12/21/2018] [Indexed: 12/04/2022] Open
Abstract
Although the End TB Strategy highlights that major global progress towards universal health coverage (UHC) and social protection are fundamental to achieving the global targets for reductions in tuberculosis (TB) incidence and deaths, there is still a long way to go to achieve them in low- and middle-income countries. A workshop on the End TB Strategy Pillar 2 in the Western Pacific Region focusing on action towards UHC and social protection was held between 27 and 29 November in 2017 at the Korean Institute of Tuberculosis in Cheonju, Republic of Korea. The workshop brought together key personnel from national TB programmes and other stakeholders or researchers with experience in this topic from six countries with a high burden of TB in the region. During the workshop, participants shared country experiences, best practices, and challenges in achieving UHC and enhancing social protection in the context of TB service delivery, and also explored policy options to address the challenges, to be applied in their respective countries. This report describes the content of the meeting and the conclusions and recommendations arising from the meeting.
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Affiliation(s)
- Kyung Hyun Oh
- Korean Institute of Tuberculosis, Cheongju-si, Chungcheongbuk-do 28158, Korea.
| | - Kalpeshsinh Rahevar
- World Health Organization Regional Office for the Western Pacific, 1000 Manila, Philippines.
| | | | - Kerri Viney
- Karolinska Institutet, 171 77 Stockholm, Sweden.
- Research School of Population Health, National Centre of Epidemiology and Population Health, Department of Global Health, Australian National University, Canberra 2601, Australia.
| | - Hongjo Choi
- Korean Institute of Tuberculosis, Cheongju-si, Chungcheongbuk-do 28158, Korea.
| | | | - Hee Jin Kim
- Korean Institute of Tuberculosis, Cheongju-si, Chungcheongbuk-do 28158, Korea.
| | - Chanly Nou
- National Center for Tuberculosis and Leprosy Control, Street 278/95, Sangkat Boeung Kebg Kang II, Khan Chamkar Morn, 1217 Phnom Penh, Cambodia.
| | - Samoeun Kim
- National Center for Tuberculosis and Leprosy Control, Street 278/95, Sangkat Boeung Kebg Kang II, Khan Chamkar Morn, 1217 Phnom Penh, Cambodia.
| | - Ge Zhu
- National Health Commission, 1 Wainan Road, Xizhimen, Xicheng District, Beijing 100044, China.
| | - Hui Zhang
- Chinese Center for Disease Control and Prevention, 155 Changbai Road, Changping District, Beijing 102206, China.
| | - Caihong Xu
- Chinese Center for Disease Control and Prevention, 155 Changbai Road, Changping District, Beijing 102206, China.
| | - Soth Bounmala
- Ministry of Health, Ban thatkhao, Sisattanack District, Rue Simeuang, 343 Vientiane, Lao PDR.
| | - Maytry Senchanthixay
- Ministry of Health, Ban thatkhao, Sisattanack District, Rue Simeuang, 343 Vientiane, Lao PDR.
| | - Enkhtamir Purevdorj
- National Center for Communicable Diseases Bayanzurkh district, Horoo 14, 13th district, Nam Yan Ju Street, Ulaanbaatar 210648, Mongolia.
| | - Ulzii-Orshikh Khaltar
- Ministry of Health, Government Building VIII, Olympic Street-2, Sukhbaatar District, Ulaanbaatar 210648, Mongolia.
| | - Ronald Paguirigan
- Health Policy Development and Planning Bureau, Department of Health, 2nd Floor Building 3, San Lazaro Compound, C. S. Gatmaitan Ave, Manila, 1003 Metro Manila, Philippines.
| | - Hansel Amoguis
- Department of Health-Region XI, J.P. Laurel Ave, Bajada, Davao City 8000, Philippines.
| | - Vu Xuan Phu
- National Lung Hospital, 463 Hoang Hoa Tham Road, Ha Noi 124302, Viet Nam.
| | - Dang Xuan Khang
- Ministry of Labour-Invalids and Social Affairs, 12 Ngo Quyen Str, Hoan Kiem District, Ha Noi 110905, Viet Nam.
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Mihalicza P, Leys M, Borbás I, Szigeti S, Biermann O, Kuchenmüller T. Qualitative assessment of opportunities and challenges to improve evidence-informed health policy-making in Hungary - an EVIPNet situation analysis pilot. Health Res Policy Syst 2018; 16:50. [PMID: 29914525 PMCID: PMC6006924 DOI: 10.1186/s12961-018-0331-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 05/24/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In evidence-informed policy-making (EIP), major knowledge gaps remain in understanding the context and possibilities for institutionalisation of knowledge translation. In 2014, the WHO Evidence-informed Policy Network (EVIPNet) Europe initiated a number of pilot countries, with Hungary among them, to engage in a 'situation analysis' (SA) in order to fill some of those gaps. This contribution discusses the results of the SA in Hungary on research-policy interactions, facilitating factors and potential barriers to establish a knowledge translation platform (KTP). METHODS In line with the EVIPNet Europe SA Manual, a document analysis, 13 interviews, 3 focus group discussions with 21 participants, and an online survey with 31 respondents were carried out from April to October, 2015. A SA aims to assess the context in which EIP takes form and seeks opportunities to establish a KTP, so information was gathered on the current practice of EIP and knowledge translation, its relevant actors, enablers and barriers for EIP, and opinions on a future KTP. Methodological and researcher triangulation resulted in a narrative synthesis of data, including a comparison with literature. A stakeholder consultation was organised to validate findings. RESULTS This study reveals that stakeholders show commitment to produce and use research evidence in Hungarian health policy-making. All stakeholders endorsed the idea of strengthening the systematic use of evidence in decision-making and favoured the idea of establishing a KTP. In line with literature on other countries, some good practices exist on the uptake of evidence in policy-making; however, a systematic approach of developing, translating and using research evidence in health policy processes is lacking. EIP is currently hampered by scattered capacity, coordination problems, high fluctuation in government, an often legalistic and a more 'symbolic' rather than practical support for knowledge translation and EIP. The article summarises recommendations on a Hungarian KTP. CONCLUSIONS Pragmatic adaptation of the SA Manual to local needs proved to be a useful mechanism to provide insight into the Hungarian EIP field and the establishment of a potential KTP. Despite the success of a KTP pilot, it remains unclear how a KTP in Hungary will be institutionalised in a sustainable way.
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Affiliation(s)
- Péter Mihalicza
- Semmelweis University Doctoral School, 2 Kőhalom street, Budapest, 1118 Hungary
| | - Mark Leys
- Vrije Universiteit Brussel, OPIH and EVIPNet Europe steering group, Jette, Belgium
| | - Ilona Borbás
- National Healthcare Service Centre, Budapest, Hungary
| | | | - Olivia Biermann
- WHO Regional Office for Europe, WHO Secretariat of EVIPNet Europe, Copenhagen, Denmark
| | - Tanja Kuchenmüller
- WHO Regional Office for Europe, WHO Secretariat of EVIPNet Europe, Copenhagen, Denmark
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Abstract
Purpose
The purpose of this paper is to better understand facilitators’ perceived role and influence on a policy dialogue’s (PD) process and impact. PDs enable interactions between policy makers, researchers and other stakeholders – one of the factors associated with promoting evidence-informed policy making.
Design/methodology/approach
This is an exploratory study based on semi-structured interviews with ten key informants from sub-Saharan Africa, the Middle East, North and South America. Participants were purposefully sampled based on their experience in facilitating or observing PDs organized by the WHO’s Evidence-informed Policy Network. Data were analyzed using a constant comparative method.
Findings
A successful PD relies on a structured process used to catalyze impact. Facilitators contribute to a successful PD through their facilitation skills, for example, helping to get to an informed judgment; knowledge, for example, about the health system; attitudes, for example, valuing the PD process over its outcomes; and personal attributes, for example, credibility. Facilitators’ involvement in preparatory and follow-up actions are equally paramount for a PD’s success. Challenges in implementing PDs can be prevented/attenuated, for example, through stakeholder analysis to identify suitable PD participants, and anticipate power constellations or potential conflicts.
Research limitations/implications
Research should focus on the overall process of a PD – especially on preparation and follow-up activities and their influence on a PD’s success.
Originality/value
Informed by harnessing practical experiences, this paper outlines facilitators’ skills, attributes, attitudes, knowledge and how these can be used to influence a PD’s success.
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Biermann O, Eckhardt M, Carlfjord S, Falk M, Forsberg BC. Collaboration between non-governmental organizations and public services in health - a qualitative case study from rural Ecuador. Glob Health Action 2016; 9:32237. [PMID: 27852423 PMCID: PMC5112349 DOI: 10.3402/gha.v9.32237] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 10/13/2016] [Accepted: 10/18/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Non-governmental organizations (NGOs) have a key role in improving health in low- and middle-income countries. Their work needs to be synergistic, complementary to public services, and rooted in community mobilization and collective action. The study explores how an NGO and its health services are perceived by the population that it serves, and how it can contribute to reducing barriers to care. DESIGN A qualitative exploratory study was conducted in remote Ecuador, characterized by its widespread poverty and lack of official governance. An international NGO collaborated closely with the public services to deliver preventative and curative health services. Data were collected using focus group discussions and semistructured interviews with purposively sampled community members, healthcare personnel, and community health workers based on their links to the health services. Conventional qualitative content analysis was used, focusing on manifest content. RESULTS Emerging themes relate to the public private partnership (PPP), the NGO and its services, and community participation. The population perceives the NGO positively, linking it to healthcare improvements. Their priority is to get services, irrespective of the provider's structure. The presence of an NGO in the operation may contribute to unrealistic expectations of health services, affecting perceptions of the latter negatively. CONCLUSIONS To avoid unrealistic expectations and dissatisfaction, and to increase and sustain the population's trust in the organization, an NGO should operate in a manner that is as integrated as possible within the existing structure. The NGO should work close to the population it serves, with services anchored in the community. PPP parties should develop a common platform with joint messages to the target population on the provider's structure, and regarding partners' roles and responsibilities. Interaction between the population and the providers on service content and their expectations is key to positive outcomes of PPP operations.
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Affiliation(s)
- Olivia Biermann
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden;
| | - Martin Eckhardt
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Siw Carlfjord
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Magnus Falk
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Birger C Forsberg
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
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Leppänen A, Biermann O, Sundberg CJ, Tomson T. Perceived feasibility of a primary care intervention for Tobacco Cessation on Prescription targeting disadvantaged groups in Sweden: a qualitative study. BMC Res Notes 2016; 9:151. [PMID: 26961759 PMCID: PMC4784339 DOI: 10.1186/s13104-016-1949-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 02/22/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is a lack of scientific evidence on how socioeconomically disadvantaged tobacco users can be reached with tobacco cessation interventions in Swedish primary healthcare (PHC). In this setting other lifestyle interventions are available by prescription, and there is the potential to develop a similar tool for tobacco cessation. The aim of this study was thus to explore the perceived feasibility and optimal design of Tobacco Cessation on Prescription (TCP) in PHC, targeting disadvantaged groups in Sweden. METHODS This qualitative study is based on semi-structured interviews with 32 participants including (1) three experts in lifestyle interventions on prescription, (2) 14 healthcare providers and (3) 15 clients from three PHC centres in socioeconomically disadvantaged areas in Stockholm where tobacco use is high. The interviews were audio-recorded and transcribed verbatim. The manifest content of the transcripts was analysed according to a modified conventional approach to content analysis. RESULTS The interviewees proposed that TCP should include a template comprising the client's information, evidence-based tobacco cessation options and choices for follow-up. They also suggested including information about the benefits of tobacco cessation, as well as empowerment and planning support tools. The participants also commented that other measures for tobacco cessation could be included on the prescription. From the clients' point of view, the perceived advantages of TCP were often linked to an emotional meaning (e.g. increased motivation to quit tobacco use, sign of support from the healthcare system to seek care for tobacco cessation). For providers, advantages with TCP were frequently related to a practical meaning (e.g. improved documentation and facilitation of tobacco cessation treatment). The disadvantages identified were mainly connected with the future implementation of TCP (e.g. low self-efficacy among clients and providers). CONCLUSIONS TCP was perceived to be a useful tool for both clients and providers, potentially facilitating a structured and effective approach to tobacco cessation in PHC, and targeting disadvantaged groups. More research is needed to develop the prescription and investigate its effectiveness and cost-effectiveness compared to current strategies for tobacco cessation in a PHC setting.
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Affiliation(s)
- Anne Leppänen
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Tomtebodavägen 18 A, 171 77, Stockholm, Sweden.
| | - Olivia Biermann
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Tomtebodavägen 18 A, 171 77, Stockholm, Sweden.
| | - Carl Johan Sundberg
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Tomtebodavägen 18 A, 171 77, Stockholm, Sweden.
- Department of Physiology and Pharmacology, Karolinska Institutet, von Eulers väg 8, 171 77, Stockholm, Sweden.
| | - Tanja Tomson
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Tomtebodavägen 18 A, 171 77, Stockholm, Sweden.
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