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Tancred T, Falkenbach M, Raven J, Caffrey M. How can intersectoral collaboration and action help improve the education, recruitment, and retention of the health and care workforce? A scoping review. Int J Health Plann Manage 2024; 39:757-780. [PMID: 38319787 DOI: 10.1002/hpm.3773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/12/2024] [Accepted: 01/25/2024] [Indexed: 02/08/2024] Open
Abstract
Inadequate numbers, maldistribution, attrition, and inadequate skill-mix are widespread health and care workforce (HCWF) challenges. Intersectoral-inclusive of different government sectors, non-state actors, and the private sector-collaboration and action are foundational to the development of a responsive and sustainable HCWF. This review presents evidence on how to work across sectors to educate, recruit, and retain a sustainable HCWF, highlighting examples of the benefits and challenges of intersectoral collaboration. We carried out a scoping review of scientific and grey literature with inclusion criteria around intersectoral governance and mechanisms for the HCWF. A framework analysis to identify and collate factors linked to the education, recruitment, and retention of the HCWF was carried out. Fifty-six documents were included. We identified a wide array of recommendations for intersectoral activity to support the education, recruitment, and retention of the HCWF. For HCWF education: formalise intersectoral decision-making bodies; align HCWF education with population health needs; expand training capacity; engage and regulate private sector training; seek international training opportunities and support; and innovate in training by leveraging digital technologies. For HCWF recruitment: ensure there is intersectoral clarity and cooperation; ensure bilateral agreements are ethical; carry out data-informed recruitment; and learn from COVID-19 about mobilising the domestic workforce. For HCWF retention: innovate around available staff, especially where staff are scarce; improve working and employment conditions; and engage the private sector. Political will and commensurate investment must underscore any intersectoral collaboration for the HCWF.
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Affiliation(s)
- Tara Tancred
- Liverpool School of Tropical Medicine (LSTM), Liverpool, UK
| | | | - Joanna Raven
- Liverpool School of Tropical Medicine (LSTM), Liverpool, UK
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Kuliya-Gwarzo A, Tancred T, Gordon D, Bates I, Raven J. Maternal anaemia care in Kano state, Nigeria: an exploratory qualitative study of experiences of uptake and provision. F1000Res 2023; 12:288. [PMID: 38434670 PMCID: PMC10905168 DOI: 10.12688/f1000research.130980.1] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/01/2023] [Indexed: 03/05/2024] Open
Abstract
Background Maternal anaemia (anaemia in pregnancy, childbirth, and the postpartum period) remains a persistent challenge, particularly in Kano State, Nigeria, which has the highest prevalence of maternal anaemia globally, at 72%. Methods We conducted a qualitative study in Murtala Muhammad Specialist Hospital in Kano State, Nigeria. We aimed to identify factors constraining uptake and provision of maternal anaemia care, exploring perspectives across different stakeholders. We carried out 10 key informant interviews with policymakers and hospital managers, 28 in-depth interviews with healthcare providers and pregnant women using antenatal services and four focus group discussions with pregnant women's husbands and mothers-in-law. Data were analysed thematically. Results Issues with provision include a lack of provider training and guidelines specific to maternal anaemia and blood transfusion, insufficient staff to meet increasing demand, and inadequate resources. Issues with uptake include the inability to afford informal user fees, distrust in health services and the blood transfusion process, and a lack of understanding of the causes, consequences, and treatment for anaemia, resulting in poor uptake of care and adherence to treatment. Conclusions This study recommends the implementation of standardized guidelines and training sessions to better support healthcare providers in offering quality services and increasing funding allocated to supporting maternal anaemia care. Education initiatives for service users and the public are also recommended to build public trust in health services and to improve understanding of maternal anaemia.
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Affiliation(s)
| | - Tara Tancred
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Daniel Gordon
- Physiotherapy, Brunel University, London, UB8 3PH, UK
| | - Imelda Bates
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Joanna Raven
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
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Pulford J, El Hajj T, Tancred T, Ding Y, Crossman S, Silvester L, Savio M, Bevan N, Tagoe N, Bates I. How international research consortia can strengthen organisations' research systems and promote a conducive environment and culture. BMJ Glob Health 2023; 8:e011419. [PMID: 37028811 PMCID: PMC10083781 DOI: 10.1136/bmjgh-2022-011419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 03/18/2023] [Indexed: 04/09/2023] Open
Abstract
Research systems and cultures have been criticised for their detrimental effect on members' mental health and well-being. Many international research programmes operate through research consortia that have the resources to make a substantial contribution to improving the research environment in their member organisations. This paper collates real-life examples from several large international consortia-based research programmes about how they strengthened organisations' research capacity. The consortia primarily involved academic partners from the UK and/or sub-Saharan Africa and covered research topics including health, natural sciences, conservation agriculture and vector control. They were partly or wholly funded by UK agencies including the Wellcome, Foreign and Commonwealth Development Office, UK Research and Innovation Fund, and the Medical Research Council and they operated for 2-10 years between 2012 and 2022.Consortia's size and ability to access and share resources among their member organisations according to need meant they were uniquely placed to target actions to address weaknesses in member organisations' research capacity, to widen networks and collaborations, and to build in sustainability of capacity gains. Consortia's actions covered: (a) individuals' knowledge and skills; (b) capacity strengthening ethos; (c) organisations' visibility and prestige; and (d) inclusive and responsive management practices. Evidence about these actions formed the basis of recommendations for funders and leaders of consortium-based programmes about how they could make more effective use of consortia's resources to enhance organisations' research systems, environments and cultures.Key lessons were that training should cover management and research leadership and should be offered beyond consortium members, including to research support staff such as technicians and managers. Consortia often tackle complex problems requiring multidisciplinary inputs, but overcoming disciplinary boundaries-and making everyone feel valued and respected-takes time and skill on the part of consortium leaders. Consortia need clear guidance from funders about their commitment to strengthening research capacity. Without this, consortia leaders may continue to prioritise research outputs over creating and embedding sustainable improvements in their organisations' research systems.
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Affiliation(s)
| | | | - Tara Tancred
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Yan Ding
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | - Martina Savio
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Natasha Bevan
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Nadia Tagoe
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Imelda Bates
- Liverpool School of Tropical Medicine, Liverpool, UK
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Turner J, Tancred T. Maternity care provision for women living with female genital mutilation/cutting: A qualitative study from a high asylum-seeking dispersal context in the UK. Int J Health Plann Manage 2023; 38:790-804. [PMID: 36808645 DOI: 10.1002/hpm.3625] [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] [Received: 10/18/2022] [Revised: 01/27/2023] [Accepted: 02/04/2023] [Indexed: 02/23/2023] Open
Abstract
OBJECTIVE To explore the perspectives of midwives and obstetrician/gynaecologists providing maternity care to women living with female genital mutilation/cutting (FGM/C) in a high asylum-seeker dispersal area in the North West of England. METHODS We carried out a qualitative study in four hospitals providing maternal health services within the North West of England, with the highest population of asylum-seeking individuals (many from high-prevalence FGM/C countries) in the UK. Participants included 13 practicing midwives and an obstetrician/gynaecologist. In-depth interviews were conducted with study participants. Data collection and analysis were carried out concurrently until theoretical saturation was reached. Data were analysed thematically to generate three key overarching themes. RESULTS There is a disconnect between Home Office dispersal policy and healthcare policy. Participants indicated that there was inconsistent identification or disclosure of FGM/C, constraining appropriate follow-up and care prior to labour and childbirth. All participants noted existing safeguarding policies and protocols, which were seen by most as being important to protect female dependants, but potentially detrimental to the patient-provider relationship and to the woman's care. Unique challenges around accessing and maintaining continuity of care for asylum-seeking women due to dispersal schemes were indicated. All participants highlighted a lack of specialised training for FGM/C to support provision of clinically appropriate and culturally sensitive care. CONCLUSIONS There is a clear need for harmony between health and social policy as well as specialised training that centres holistic wellbeing for the woman living with FGM/C, particularly where there are increased numbers of asylum-seeking women from high-prevalence FGM/C countries.
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Affiliation(s)
- Jessica Turner
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Tara Tancred
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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Egid BR, Roura M, Aktar B, Amegee Quach J, Chumo I, Dias S, Hegel G, Jones L, Karuga R, Lar L, López Y, Pandya A, Norton TC, Sheikhattari P, Tancred T, Wallerstein N, Zimmerman E, Ozano K. 'You want to deal with power while riding on power': global perspectives on power in participatory health research and co-production approaches. BMJ Glob Health 2021; 6:e006978. [PMID: 34764147 PMCID: PMC8587355 DOI: 10.1136/bmjgh-2021-006978] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 10/23/2021] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Power relations permeate research partnerships and compromise the ability of participatory research approaches to bring about transformational and sustainable change. This study aimed to explore how participatory health researchers engaged in co-production research perceive and experience 'power', and how it is discussed and addressed within the context of research partnerships. METHODS Five online workshops were carried out with participatory health researchers working in different global contexts. Transcripts of the workshops were analysed thematically against the 'Social Ecology of Power' framework and mapped at the micro (individual), meso (interpersonal) or macro (structural) level. RESULTS A total of 59 participants, with participatory experience in 24 different countries, attended the workshops. At the micro level, key findings included the rarity of explicit discussions on the meaning and impact of power, the use of reflexivity for examining assumptions and power differentials, and the perceived importance of strengthening co-researcher capacity to shift power. At the meso level, participants emphasised the need to manage co-researcher expectations, create spaces for trusted dialogue, and consider the potential risks faced by empowered community partners. Participants were divided over whether gatekeeper engagement aided the research process or acted to exclude marginalised groups from participating. At the macro level, colonial and 'traditional' research legacies were acknowledged to have generated and maintained power inequities within research partnerships. CONCLUSIONS The 'Social Ecology of Power' framework is a useful tool for engaging with power inequities that cut across the social ecology, highlighting how they can operate at the micro, meso and macro level. This study reiterates that power is pervasive, and that while many researchers are intentional about engaging with power, actions and available tools must be used more systematically to identify and address power imbalances in participatory research partnerships, in order to contribute to improved equity and social justice outcomes.
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Affiliation(s)
- Beatrice R Egid
- Department of Vector Biology, Liverpool School of Tropical Medicine, Liverpool, UK
| | - María Roura
- School of Public Health, University College Cork, Cork, Ireland
| | - Bachera Aktar
- James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
| | - Jessica Amegee Quach
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Ivy Chumo
- Urbanisation and Wellbeing Unit, African Population and Health Research Center, Nairobi, Kenya
| | - Sónia Dias
- NOVA National School of Public Health, Public Health Research Centre, Universidade Nova de Lisboa and Comprehensive Health Research Centre, Lisboa, Portugal
| | - Guillermo Hegel
- INCAP Research Center for Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama, Guatemala City, Guatemala
| | - Laundette Jones
- School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Robinson Karuga
- Department of Research and Strategic Information, LVCT Health, Nairobi, Kenya
| | - Luret Lar
- Department of Community Medicine, University of Jos, Jos, Nigeria
| | - Yaimie López
- Department of Vector Biology, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Apurvakumar Pandya
- Parul Institute of Public Health, Faculty of Medicine, Parul University, Vadodara, Gujarat, India
| | | | - Payam Sheikhattari
- School of Community Health and Policy, Prevention Sciences Research Center, Morgan State University, Baltimore, Maryland, USA
| | - Tara Tancred
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Nina Wallerstein
- Center for Participatory Research, College of Population Health, University of New Mexico, Albuquerque, New Mexico, USA
| | - Emily Zimmerman
- Center on Society and Health, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Kim Ozano
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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Ponsford R, Meiksin R, Bragg S, Crichton J, Emmerson L, Tancred T, Tilouche N, Morgan G, Gee P, Young H, Hadley A, Campbell R, Bonell C. Co-production of two whole-school sexual health interventions for English secondary schools: positive choices and project respect. Pilot Feasibility Stud 2021; 7:50. [PMID: 33597013 PMCID: PMC7888187 DOI: 10.1186/s40814-020-00752-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 03/25/2020] [Accepted: 12/16/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Whole-school interventions represent promising approaches to promoting adolescent sexual health, but they have not been rigorously trialled in the UK and it is unclear if such interventions are feasible for delivery in English secondary schools. The importance of involving intended beneficiaries, implementers and other key stakeholders in the co-production of such complex interventions prior to costly implementation and evaluation studies is widely recognised. However, practical accounts of such processes remain scarce. We report on co-production with specialist providers, students, school staff, and other practice and policy professionals of two new whole-school sexual heath interventions for implementation in English secondary schools. METHODS Formative qualitative inquiry involving 75 students aged 13-15 and 23 school staff. A group of young people trained to advise on public health research were consulted on three occasions. Twenty-three practitioners and policy-makers shared their views at a stakeholder event. Detailed written summaries of workshops and events were prepared and key themes identified to inform the design of each intervention. RESULTS Data confirmed acceptability of addressing unintended teenage pregnancy, sexual health and dating and relationships violence via multi-component whole-school interventions and of curriculum delivery by teachers (providing appropriate teacher selection). The need to enable flexibility for the timetabling of lessons and mode of parent communication; ensure content reflected the reality of young people's lives; and develop prescriptive teaching materials and robust school engagement strategies to reflect shrinking capacity for schools to implement public-health interventions were also highlighted and informed intervention refinements. Our research further points to some of the challenges and tensions involved in co-production where stakeholder capacity may be limited or their input may conflict with the logic of interventions or what is practicable within the constraints of a trial. CONCLUSIONS Multi-component, whole-school approaches to addressing sexual health that involve teacher delivered curriculum may be feasible for implementation in English secondary schools. They must be adaptable to individual school settings; involve careful teacher selection; limit additional burden on staff; and accurately reflect the realities of young people's lives. Co-production can reduce research waste and may be particularly useful for developing complex interventions, like whole-school sexual health interventions, that must be adaptable to varying institutional contexts and address needs that change rapidly. When co-producing, potential limitations in relation to the representativeness of participants, the 'depth' of engagement necessary as well as the burden on participants and how they will be recompensed must be carefully considered. Having well-defined, transparent procedures for incorporating stakeholder input from the outset are also essential. Formal feasibility testing of both co-produced interventions in English secondary schools via cluster RCT is warranted. TRIAL REGISTRATION Project Respect: ISRCTN12524938 . Positive Choices: ISRCTN65324176.
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Affiliation(s)
- Ruth Ponsford
- Department of Public Health, Environments & Society, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
| | - Rebecca Meiksin
- Department of Public Health, Environments & Society, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Sara Bragg
- Centre for Sociology of Education and Equity, UCL Institute of Education, 20 Bedford Way, London, WC1H 0AL, UK
| | - Joanna Crichton
- Population Health Sciences, Bristol Medical School, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Lucy Emmerson
- Sex Education Forum, National Children's Bureau, 23 Mentmore Terrace, London, E8 3PN, UK
| | - Tara Tancred
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Nerissa Tilouche
- Department of Public Health, Environments & Society, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Gemma Morgan
- Population Health Sciences, Bristol Medical School, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Pete Gee
- School of Social Sciences, Cardiff University, 1-3 Museum Place, Cardiff, CF10 3BD, UK
| | - Honor Young
- School of Social Sciences, Cardiff University, 1-3 Museum Place, Cardiff, CF10 3BD, UK
| | - Alison Hadley
- Teenage Pregnancy Knowledge Exchange, University of Bedfordshire, University Square, Luton, LU1 3JU, UK
| | - Rona Campbell
- Population Health Sciences, Bristol Medical School, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Chris Bonell
- Department of Public Health, Environments & Society, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
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Manzi F, Marchant T, Hanson C, Schellenberg J, Mkumbo E, Mlaguzi M, Tancred T. Harnessing the health systems strengthening potential of quality improvement using realist evaluation: an example from southern Tanzania. Health Policy Plan 2020; 35:ii9-ii21. [PMID: 33156943 PMCID: PMC7646731 DOI: 10.1093/heapol/czaa128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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] [Accepted: 09/03/2020] [Indexed: 11/13/2022] Open
Abstract
Quality improvement (QI) is a problem-solving approach in which stakeholders identify context-specific problems and create and implement strategies to address these. It is an approach that is increasingly used to support health system strengthening, which is widely promoted in Sub-Saharan Africa. However, few QI initiatives are sustained and implementation is poorly understood. Here, we propose realist evaluation to fill this gap, sharing an example from southern Tanzania. We use realist evaluation to generate insights around the mechanisms driving QI implementation. These insights can be harnessed to maximize capacity strengthening in QI and to support its operationalization, thus contributing to health systems strengthening. Realist evaluation begins by establishing an initial programme theory, which is presented here. We generated this through an elicitation approach, in which multiple sources (theoretical literature, a document review and previous project reports) were collated and analysed retroductively to generate hypotheses about how the QI intervention is expected to produce specific outcomes linked to implementation. These were organized by health systems building blocks to show how each block may be strengthened through QI processes. Our initial programme theory draws from empowerment theory and emphasizes the self-reinforcing nature of QI: the more it is implemented, the more improvements result, further empowering people to use it. We identified that opportunities that support skill- and confidence-strengthening are essential to optimizing QI, and thus, to maximizing health systems strengthening through QI. Realist evaluation can be used to generate rich implementation data for QI, showcasing how it can be supported in ‘real-world’ conditions for health systems strengthening.
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Affiliation(s)
- Fatuma Manzi
- Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Tanya Marchant
- Department of Disease Control, London School of Hygiene and Tropical Medicine, UK
| | - Claudia Hanson
- Department of Public Health Sciences, Karolinska Institutet, Sweden
| | - Joanna Schellenberg
- Department of Disease Control, London School of Hygiene and Tropical Medicine, UK
| | - Elibariki Mkumbo
- Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Mwanaidi Mlaguzi
- Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Tara Tancred
- Department of Disease Control, London School of Hygiene and Tropical Medicine, UK
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Rousseva C, Kammath V, Tancred T, Smith H. Health workers' views on audit in maternal and newborn healthcare in LMICs: a qualitative evidence synthesis. Trop Med Int Health 2020; 25:525-539. [PMID: 31994815 DOI: 10.1111/tmi.13377] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 11/30/2022]
Abstract
OBJECTIVES To identify and summarise health workers' views on the use of audit as a method to improve the quality of maternal and newborn healthcare in low- and middle-income countries (LMICs). METHODS We conducted a qualitative evidence synthesis. PubMed, CINAHL and Global Health databases were searched using keywords, synonyms and MeSH headings for 'audit', 'views' and 'health workers' to find papers that used qualitative methods to explore health workers' views on audit in LMICs. Titles and abstracts were then screened for inclusion. The remaining full-text papers were then screened. The final included papers were quality assessed using the Critical Appraisal Skills Programme tool for qualitative research. Data on audit type and health workers' perceptions were extracted and analysed using thematic synthesis. RESULTS Nineteen papers were included in the review, most from sub-Saharan Africa. Health workers generally held favourable views of audit and expressed dedication to the process. Similarly, they described positive experiences conducting audit. The main barriers to implementing audit were the presence of a blame culture, inadequate training and the lack of time and resources to conduct audit. Health workers' motivation and dedication to the audit process helped to overcome such barriers. CONCLUSIONS Health workers are dedicated to the process of audit, but must be supported with training, leadership and adequate resources to use it. Decision-makers and technical partners supporting audit should focus on improving audit training and finding ways to conduct audit without requiring too much staff time.
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Affiliation(s)
| | | | - Tara Tancred
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK
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Bonell C, Allen E, Warren E, McGowan J, Bevilacqua L, Jamal F, Sadique Z, Legood R, Wiggins M, Opondo C, Mathiot A, Sturgess J, Paparini S, Fletcher A, Perry M, West G, Tancred T, Scott S, Elbourne D, Christie D, Bond L, Viner RM. Modifying the secondary school environment to reduce bullying and aggression: the INCLUSIVE cluster RCT. Public Health Res 2019. [DOI: 10.3310/phr07180] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundBullying, aggression and violence among children and young people are some of the most consequential public mental health problems.ObjectivesThe INCLUSIVE (initiating change locally in bullying and aggression through the school environment) trial evaluated the Learning Together intervention, which involved students in efforts to modify their school environment using restorative approaches and to develop social and emotional skills. We hypothesised that in schools receiving Learning Together there would be lower rates of self-reported bullying and perpetration of aggression and improved student biopsychosocial health at follow-up than in control schools.DesignINCLUSIVE was a cluster randomised trial with integral economic and process evaluations.SettingForty secondary schools in south-east England took part. Schools were randomly assigned to implement the Learning Together intervention over 3 years or to continue standard practice (controls).ParticipantsA total of 6667 (93.6%) students participated at baseline and 5960 (83.3%) students participated at final follow-up. No schools withdrew from the study.InterventionSchools were provided with (1) a social and emotional curriculum, (2) all-staff training in restorative approaches, (3) an external facilitator to help convene an action group to revise rules and policies and to oversee intervention delivery and (4) information on local needs to inform decisions.Main outcome measuresSelf-reported experience of bullying victimisation (Gatehouse Bullying Scale) and perpetration of aggression (Edinburgh Study of Youth Transitions and Crime school misbehaviour subscale) measured at 36 months. Intention-to-treat analysis using longitudinal mixed-effects models.ResultsPrimary outcomes – Gatehouse Bullying Scale scores were significantly lower among intervention schools than among control schools at 36 months (adjusted mean difference –0.03, 95% confidence interval –0.06 to 0.00). There was no evidence of a difference in Edinburgh Study of Youth Transitions and Crime scores. Secondary outcomes – students in intervention schools had higher quality of life (adjusted mean difference 1.44, 95% confidence interval 0.07 to 2.17) and psychological well-being scores (adjusted mean difference 0.33, 95% confidence interval 0.00 to 0.66), lower psychological total difficulties (Strengths and Difficulties Questionnaire) score (adjusted mean difference –0.54, 95% confidence interval –0.83 to –0.25), and lower odds of having smoked (odds ratio 0.58, 95% confidence interval 0.43 to 0.80), drunk alcohol (odds ratio 0.72, 95% confidence interval 0.56 to 0.92), been offered or tried illicit drugs (odds ratio 0.51, 95% confidence interval 0.36 to 0.73) and been in contact with police in the previous 12 months (odds ratio 0.74, 95% confidence interval 0.56 to 0.97). The total numbers of reported serious adverse events were similar in each arm. There were no changes for staff outcomes. Process evaluation – fidelity was variable, with a reduction in year 3. Over half of the staff were aware that the school was taking steps to reduce bullying and aggression. Economic evaluation – mean (standard deviation) total education sector-related costs were £116 (£47) per pupil in the control arm compared with £163 (£69) in the intervention arm over the first two facilitated years, and £63 (£33) and £74 (£37) per pupil, respectively, in the final, unfacilitated, year. Overall, the intervention was associated with higher costs, but the mean gain in students’ health-related quality of life was slightly higher in the intervention arm. The incremental cost per quality-adjusted life year was £13,284 (95% confidence interval –£32,175 to £58,743) and £1875 (95% confidence interval –£12,945 to £16,695) at 2 and 3 years, respectively.LimitationsOur trial was carried out in urban and periurban settings in the counties around London. The large number of secondary outcomes investigated necessitated multiple statistical testing. Fidelity of implementation of Learning Together was variable.ConclusionsLearning Together is effective across a very broad range of key public health targets for adolescents.Future workFurther studies are required to assess refined versions of this intervention in other settings.Trial registrationCurrent Controlled Trials ISRCTN10751359.FundingThis project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full inPublic Health Research; Vol. 7, No. 18. See the NIHR Journals Library website for further project information. Additional funding was provided by the Educational Endowment Foundation.
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Affiliation(s)
- Chris Bonell
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, UK
| | - Elizabeth Allen
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Emily Warren
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, UK
| | - Jennifer McGowan
- Institute of Child Health, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Leonardo Bevilacqua
- Institute of Child Health, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Farah Jamal
- Department of Social Science, University College London Institute of Education, London, UK
| | - Zia Sadique
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Rosa Legood
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Meg Wiggins
- Department of Social Science, University College London Institute of Education, London, UK
| | - Charles Opondo
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Anne Mathiot
- Institute of Child Health, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Joanna Sturgess
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Sara Paparini
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, UK
| | - Adam Fletcher
- School of Social Sciences, Cardiff University, Cardiff, UK
| | | | - Grace West
- Institute of Child Health, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Tara Tancred
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, UK
| | - Stephen Scott
- Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Diana Elbourne
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Deborah Christie
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Lyndal Bond
- College of Health and Biomedicine, Victoria University, Melbourne, VIC, Australia
| | - Russell M Viner
- Institute of Child Health, University College London Great Ormond Street Institute of Child Health, London, UK
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10
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Tancred T, Melendez-Torres GJ, Paparini S, Fletcher A, Stansfield C, Thomas J, Campbell R, Taylor S, Bonell C. Interventions integrating health and academic education in schools to prevent substance misuse and violence: a systematic review. Public Health Res 2019. [DOI: 10.3310/phr07170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Schools struggle to timetable health education. Interventions integrating academic and health education to reduce substance use and violence offer promise. No current systematic reviews examine such interventions.
Objectives
To review evidence to explore the following questions: (1) what types of interventions integrating health and academic education in schools serving those aged 4–18 years have been evaluated? (2) What theories of change inform these interventions? (3) What factors facilitate or limit the successful implementation and receipt of such interventions, and what are the implications for the delivery of such implementations in the UK? (4) How effective are such interventions in reducing smoking and violence and the use of alcohol and drugs, and at increasing attainment? Does this vary by students’ sociodemographic characteristics? (5) What factors appear to influence the effectiveness of such interventions?
Data sources
In total, 19 databases were searched from 18 November to 22 December 2015, updating searches for outcome evaluations for violence on 28 February 2018 and for substance use on 14 May 2018. References were extracted from included studies and authors contacted.
Review methods
Included studies reported on theories of change, and process or outcome evaluations of interventions that integrated academic and health education to reduce substance use and/or violence. References were screened on the title/abstract and then on the full report. Data extraction and appraisal used Cochrane, Evidence for Policy and Practice Information Centre and other established tools. Theories of change and process data were qualitatively synthesised. Outcome evaluations were synthesised narratively and meta-analytically.
Results
In total, 78,451 unique references were originally identified and 62 reports included. Search updates on 28 February and 14 May 2018 retrieved a further 2355 and 1945 references, respectively, resulting in the inclusion of six additional reports. Thirty-nine reports described theories, 16 reports (15 studies) evaluated process and 41 reports (16 studies) evaluated outcomes. Multicomponent interventions are theorised to erode ‘boundaries’ (strengthen relationships) between academic and health education, teachers and students, behaviour in classrooms and in the wider school, and schools and families. Teachers, pro-social peers and parents are theorised to act as role models and reinforcers of healthy behaviours learnt in lessons. There was clear evidence that interventions are facilitated by supportive senior management and alignment with the schools’ ethos, collaborative and supportive teaching environments, and positive pre-existing student, teacher and parent attitudes towards interventions. The barriers were overburdened teachers who had little time to both learn and implement integrated curricula. The strongest evidence for effectiveness was found for the reduction of substance use in school key stages (KSs) 2 and 3. For example, a meta-analysis for substance use at KS3 reported a mean difference of –0.09 (95% confidence interval –0.17 to –0.01). A meta-analysis for effectiveness in reducing violence victimisation in KS2 found no effect. There was mixed evidence for effects on academic outcomes, with meta-analysis precluded by methodological heterogeneity.
Limitations
Study quality was variable. Integration was sometimes not emphasised in theories of change.
Conclusions
These interventions are undertheorised but involve multiple forms of boundary erosion. There is clear evidence of characteristics affecting implementation. Interventions are likely to have the greatest impact on substance use. These programmes may be effective in reducing substance use but do not appear to reduce violence and findings on educational impacts are mixed.
Future work
Future evaluations should assess interventions with clearer theories of change and examine academic outcomes alongside violence and substance use outcomes.
Study registration
This study is registered as PROSPERO CRD42015026464.
Funding
The National Institute for Health Research Public Health Research programme.
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Affiliation(s)
- Tara Tancred
- Department of Social and Environmental Health Research, London School of Hygiene & Tropical Medicine, London, UK
| | - GJ Melendez-Torres
- Development and Evaluation of Complex Interventions for Public Health Improvement, School of Social Sciences, Cardiff University, Cardiff, UK
| | - Sara Paparini
- Department of Social and Environmental Health Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Adam Fletcher
- Development and Evaluation of Complex Interventions for Public Health Improvement, School of Social Sciences, Cardiff University, Cardiff, UK
| | - Claire Stansfield
- Evidence for Policy and Practice Information and Co-ordinating Centre, Social Science Research Unit, University College London Institute of Education, University College London, London, UK
| | - James Thomas
- Evidence for Policy and Practice Information and Co-ordinating Centre, Social Science Research Unit, University College London Institute of Education, University College London, London, UK
| | - Rona Campbell
- Development and Evaluation of Complex Interventions for Public Health Improvement, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Suzanne Taylor
- Department of Social and Environmental Health Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Chris Bonell
- Department of Social and Environmental Health Research, London School of Hygiene & Tropical Medicine, London, UK
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Abstract
Postpartum haemorrhage contributes to 25% of maternal deaths worldwide, rising to 40% in sub-Saharan Africa. Treatment of postpartum haemorrhage-particularly for women with anaemia -requires timely, quality blood transfusions. There are a number of barriers to the provision of transfusion services, especially in low- and middle-income settings where the need is the greatest. These include unavailability of blood, unsafe blood, poor uptake of labour and delivery care, difficulties getting blood to transfusing facilities and poor documentation of patient information. Examples of innovative and practical solutions to overcome these barriers are highlighted.
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Affiliation(s)
- Tara Tancred
- International Public Health, Liverpool School of Tropical Medicine, UK.
| | - Imelda Bates
- International Public Health, Liverpool School of Tropical Medicine, UK
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Shamba D, Tancred T, Hanson C, Wachira J, Manzi F. Delayed illness recognition and multiple referrals: a qualitative study exploring care-seeking trajectories contributing to maternal and newborn illnesses and death in southern Tanzania. BMC Health Serv Res 2019; 19:225. [PMID: 30975142 PMCID: PMC6460539 DOI: 10.1186/s12913-019-4019-z] [Citation(s) in RCA: 5] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Accepted: 03/18/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Maternal and neonatal mortality remain high in southern Tanzania despite an increasing number of births occurring in health facilities. In search for reasons for the persistently high mortality rates, we explored illness recognition, decision-making and care-seeking for cases of maternal and neonatal illness and death. METHODS We conducted 48 in-depth interviews (16 participants who experienced maternal illnesses, 16 mothers whose newborns experienced illness, eight mothers whose newborns died, and eight family members of a household with a maternal death), and five focus group discussions with community leaders in two districts of Mtwara region. Thematic analysis was used for interpretation of findings. RESULTS Our data indicated relatively timely illness recognition and decision-making for maternal complications. In contrast, families reported difficulties interpreting newborn illnesses. Decisions on care-seeking involved both the mother and her partner or other family members. Delays in care-seeking were therefore also reported in absence of the husband, or at night. Primary-level facilities were first consulted. Most respondents had to consult more than one facility and described difficulties accessing and receiving appropriate care. Definitive treatment for maternal and newborn complications was largely only available in hospitals. CONCLUSIONS Delays in reaching a facility that can provide appropriate care is influenced by multiple referrals from one facility to another. Referral and care-seeking advice should include direct care-seeking at hospitals in case of severe complications and primary facilities should facilitate prompt referral.
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Affiliation(s)
- Donat Shamba
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania.
| | - Tara Tancred
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Claudia Hanson
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK.,Department of Public Health Sciences-Global Health, Karolinska Institute, Stockholm, Sweden
| | - Juddy Wachira
- School of Medicine/AMPATH, Moi University, Nairobi, Kenya
| | - Fatuma Manzi
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
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Tancred T, Paparini S, Melendez-Torres GJ, Fletcher A, Thomas J, Campbell R, Bonell C. Interventions integrating health and academic interventions to prevent substance use and violence: a systematic review and synthesis of process evaluations. Syst Rev 2018; 7:227. [PMID: 30522529 PMCID: PMC6284294 DOI: 10.1186/s13643-018-0886-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [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: 05/23/2018] [Accepted: 11/16/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Within increasingly constrained school timetables, interventions that integrate academic and health education to reduce substance use and violence may hold promise as a category of intervention that can positively affect both academic and health outcomes. There are no current systematic reviews exploring the effectiveness of such interventions or factors that affect their implementation. METHODS A total of 19 bibliographic databases and 32 websites were searched. References were also extracted from the reference lists of included studies, and experts and authors were contacted to identify relevant studies. We included reports with no restrictions on language or date. References were screened on title/abstract and those not thus excluded were screened on full report. Data extraction and appraisal followed the Critical Appraisal Skills Programme, Evidence for Policy and Practice Information and Co-ordinating Centre and Cochrane tools. Extracted process data were qualitatively meta-synthesised for common themes. RESULTS Seventy-eight thousand four hundred fifty-one unique references were identified, and 62 reports were included. A total of 16 reports (reporting on 15 studies of 12 interventions) evaluated process. Key facilitators of integrated academic and health curricula were supportive senior management and alignment of the intervention with school ethos; a positive teaching environment, including positive perceptions around the ability to be flexible in the adaptation and delivery of integrated academic and health curricula; positive pre-existing student and teacher attitudes towards intervention content; and parental support of interventions, largely through reinforcement of messaging at home. Important barriers were over-burdened teachers, with little time to learn and implement integrated curricula. CONCLUSION Several useful facilitating and inhibiting factors linked to the implementation of interventions that integrate academic and health education for reduced substance use and/or violence were identified, providing tentative but insightful evidence of context-specific issues that may impact intervention success. However, overall, there is still a considerable gap in our understanding of how to achieve the successful implementation of these interventions.
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Affiliation(s)
- Tara Tancred
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, 15–17 Tavistock Place, London, WC1H 9SH UK
| | - Sara Paparini
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, 15–17 Tavistock Place, London, WC1H 9SH UK
| | - G. J. Melendez-Torres
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL UK
| | - Adam Fletcher
- Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), School of Social Sciences, Cardiff University, Cardiff, CF10 3WT UK
| | - James Thomas
- EPPI-Centre, Department of Social Science, UCL, London, WC1H ONR UK
| | - Rona Campbell
- Department of Population Health Sciences, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Chris Bonell
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, 15–17 Tavistock Place, London, WC1H 9SH UK
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Tancred T, Paparini S, Melendez-Torres GJ, Thomas J, Fletcher A, Campbell R, Bonell C. A systematic review and synthesis of theories of change of school-based interventions integrating health and academic education as a novel means of preventing violence and substance use among students. Syst Rev 2018; 7:190. [PMID: 30424812 PMCID: PMC6234552 DOI: 10.1186/s13643-018-0862-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 10/30/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Schools can play an important role in promoting health. However, many education policies and institutions are increasingly emphasising academic attainment targets, which appear to be diminishing the time available for health education lessons. Interventions that integrate both health and academic learning may present an ideal solution, simultaneously addressing health education and academic development. The theories of change underlying these interventions are therefore of interest, but are poorly studied. METHODS A systematic review of evaluations of interventions that integrate academic and health education for reduced substance use and/or violence was carried out. As part of this, reports describing theory were assessed for quality and data extracted. Theoretical data were synthesised within and across individual interventions using reciprocal translation and meta-ethnographic line of argument synthesis to produce an overall theory of change for interventions that integrate health and academic education to prevent substance use and violence. RESULTS Forty-eight reports provided theoretical descriptions of 18 interventions. An overarching theory that emerged was that eroding 'boundaries' at multiple and mutually reinforcing levels-by integrating academic and health education, by transforming relationships between teachers and students, by generalising learning from classrooms to the wider school environment and by ensuring consistent messages from schools and families-is intended to lead to the development of a community of engaged students oriented towards pro-social behaviour and away from substance use, violence and other risk behaviours. CONCLUSIONS Eroding 'boundaries' between health and academic education, teachers and students, classrooms and the wider school and schools and families were seen to be the most critical to establishing new frameworks of family, classroom or school organisation that are conducive to promoting both academic and social-emotional outcomes. Whether such interventions are feasible to implement and effective in reducing risk behaviours will be examined in other reports arising from the review.
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Affiliation(s)
- Tara Tancred
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, 15–17 Tavistock Place, London, WC1H 9SH UK
| | - Sara Paparini
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, 15–17 Tavistock Place, London, WC1H 9SH UK
| | - G. J. Melendez-Torres
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL UK
| | - James Thomas
- Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre), Social Science Research Unit, University College London Institute of Education, WC1H ONR, London, UK
| | - Adam Fletcher
- Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), School of Social Sciences, Cardiff University, Cardiff, CF10 3WT UK
| | - Rona Campbell
- Department of Population Health Sciences, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Chris Bonell
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, 15–17 Tavistock Place, London, WC1H 9SH UK
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15
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Melendez-Torres GJ, Tancred T, Fletcher A, Campbell R, Thomas J, Bonell C. Integration of academic and health education for the prevention of physical aggression and violence in young people: systematic review, narrative synthesis and intervention components analysis. BMJ Open 2018; 8:e020793. [PMID: 30244206 PMCID: PMC6157571 DOI: 10.1136/bmjopen-2017-020793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 11/24/2017] [Revised: 06/22/2018] [Accepted: 08/20/2018] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES To systematically review evidence on the effectiveness of interventions including integration of academic and health education for reducing physical aggression and violence, and describe the content of these interventions. DATA SOURCES Between November and December 2015, we searched 19 databases and 32 websites and consulted key experts in the field. We updated our search in February 2018. ELIGIBILITY CRITERIA We included randomised trials of school-based interventions integrating academic and health education in students aged 4-18 and not targeted at health-related subpopulations (eg, learning or developmental difficulties). We included evaluations reporting a measure of interpersonal violence or aggression. DATA EXTRACTION AND ANALYSIS Data were extracted independently in duplicate, interventions were analysed to understand similarities and differences and outcomes were narratively synthesised by key stage (KS). RESULTS We included 13 evaluations of 10 interventions reported in 20 papers. Interventions included either full or partial integration, incorporated a variety of domains beyond the classroom, and used literature, local development or linking of study skills and health promoting skills. Evidence was concentrated in KS2, with few evaluations in KS3 or KS4, and evaluations had few consistent effects; evaluations in KS3 and KS4 did not suggest effectiveness. DISCUSSION Integration of academic and health education may be a promising approach, but more evidence is needed. Future research should consider the 'lifecourse' aspects of these interventions; that is, do they have a longitudinal effect? Evaluations did not shed light on the value of different approaches to integration.
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Affiliation(s)
| | - Tara Tancred
- Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Rona Campbell
- DECIPHer, Bristol Medical School, University of Bristol, Bristol, UK
| | - James Thomas
- EPPI-Centre, UCL Institute of Education, University College London, London, UK
| | - Christopher Bonell
- Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, London, UK
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Tancred T, Mandu R, Hanson C, Okuga M, Manzi F, Peterson S, Schellenberg J, Waiswa P, Marchant T. How people-centred health systems can reach the grassroots: experiences implementing community-level quality improvement in rural Tanzania and Uganda. Health Policy Plan 2018; 33:e1-e13. [PMID: 29304250 DOI: 10.1093/heapol/czu070] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2014] [Indexed: 01/01/2023] Open
Abstract
Background Quality improvement (QI) methods engage stakeholders in identifying problems, creating strategies called change ideas to address those problems, testing those change ideas and scaling them up where successful. These methods have rarely been used at the community level in low-income country settings. Here we share experiences from rural Tanzania and Uganda, where QI was applied as part of the Expanded Quality Management Using Information Power (EQUIP) intervention with the aim of improving maternal and newborn health. Village volunteers were taught how to generate change ideas to improve health-seeking behaviours and home-based maternal and newborn care practices. Interaction was encouraged between communities and health staff. Aim To describe experiences implementing EQUIP's QI approach at the community level. Methods A mixed methods process evaluation of community-level QI was conducted in Tanzania and a feasibility study in Uganda. We outlined how village volunteers were trained in and applied QI techniques and examined the interaction between village volunteers and health facilities, and in Tanzania, the interaction with the wider community also. Results Village volunteers had the capacity to learn and apply QI techniques to address local maternal and neonatal health problems. Data collection and presentation was a persistent challenge for village volunteers, overcome through intensive continuous mentoring and coaching. Village volunteers complemented health facility staff, particularly to reinforce behaviour change on health facility delivery and birth preparedness. There was some evidence of changing social norms around maternal and newborn health, which EQUIP helped to reinforce. Conclusions Community-level QI is a participatory research approach that engaged volunteers in Tanzania and Uganda, putting them in a central position within local health systems to increase health-seeking behaviours and improve preventative maternal and newborn health practices.
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Affiliation(s)
- Tara Tancred
- Ifakara Health Institute, Dar es Salaam, Tanzania.,Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Rogers Mandu
- Makerere University School of Public Health, Kampala, Uganda
| | - Claudia Hanson
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK.,Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Monica Okuga
- Makerere University School of Public Health, Kampala, Uganda
| | - Fatuma Manzi
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Stefan Peterson
- Makerere University School of Public Health, Kampala, Uganda.,Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.,The Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Joanna Schellenberg
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Peter Waiswa
- Makerere University School of Public Health, Kampala, Uganda.,Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Tanya Marchant
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
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Melendez-Torres GJ, Tancred T, Fletcher A, Thomas J, Campbell R, Bonell C. Does integrated academic and health education prevent substance use? Systematic review and meta-analyses. Child Care Health Dev 2018; 44:516-530. [PMID: 29446116 DOI: 10.1111/cch.12558] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Revised: 01/16/2018] [Accepted: 01/21/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Prevention of substance (alcohol, tobacco, illegal/legal drug) use in adolescents is a public health priority. As the scope for school-based health education is constrained in school timetables, interventions integrating academic and health education have gained traction in the UK and elsewhere, though evidence for their effectiveness remains unclear. We sought to synthesize the effectiveness of interventions integrating academic and health education for the prevention of substance use. METHODS We searched 19 databases between November and December 2015, among other methods. We included randomized trials of interventions integrating academic and health education targeting school students aged 4-18 and reporting substance use outcomes. We excluded interventions for specific health-related subpopulations (e.g., children with behavioural difficulties). Data were extracted independently in duplicate. Outcomes were synthesized by school key stage (KS) using multilevel meta-analyses, for substance use, overall and by type. RESULTS We identified 7 trials reporting substance use. Interventions reduced substance use generally in years 7-9 (KS3) based on 5 evaluations (d = -0.09, 95% CI [-0.17, -0.01], I2 = 35%), as well as in years 10-11 (KS4) based on 3 evaluations (-0.06, [-0.09, -0.02]; I2 = 0%). Interventions were broadly effective for reducing specific alcohol, tobacco, and drug use in both KS groups. CONCLUSIONS Evidence quality was highly variable. Findings for years 3-6 and 12-13 could not be meta-analysed, and we could not assess publication bias. Interventions appear to have a small but significant effect reducing substance use. Specific methods of integrating academic and health education remain poorly understood.
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Affiliation(s)
| | - T Tancred
- Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, London, UK
| | - A Fletcher
- British Heart Foundation Cymru, Cardiff, UK
| | - J Thomas
- EPPI-Centre, UCL Institute of Education, London, UK
| | - R Campbell
- DECIPHer, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - C Bonell
- Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, London, UK
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Tancred T, Fletcher A, Melendez-Torres GJ, Thomas J, Campbell R, Bonell C. Integrating Health Education in Academic Lessons: Is This the Future of Health Education in Schools? J Sch Health 2017; 87:807-810. [PMID: 29023837 DOI: 10.1111/josh.12554] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 02/21/2017] [Accepted: 02/23/2017] [Indexed: 06/07/2023]
Affiliation(s)
- Tara Tancred
- London School of Hygiene and Tropical Medicine, 219, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Adam Fletcher
- Cardiff University, Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), School of Social Sciences, Cardiff University, Cardiff, CF10 3WT, UK
| | | | - James Thomas
- UCL Institute of Education, 18 Woburn Square, London WC1H 0NR, UK
| | - Rona Campbell
- School of Social and Community Medicine, University of Bristol, Office 4.06, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Chris Bonell
- London School of Hygiene and Tropical Medicine, 218, 15-17 Tavistock Place, London WC1H 9SH, UK
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Tancred T, Manzi F, Schellenberg J, Marchant T. Facilitators and Barriers of Community-Level Quality Improvement for Maternal and Newborn Health in Tanzania. Qual Health Res 2017; 27:738-749. [PMID: 27022034 DOI: 10.1177/1049732316638831] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
A quality improvement intervention for maternal and newborn health was carried out in southern Tanzania at the community level. It sought to improve health-seeking behaviors and uptake of community-level maternal and newborn health practices. A process evaluation populated using data primarily from in-depth interviews and focus group discussions with the intervention's implementers was undertaken in four villages receiving the intervention to evaluate the intervention's implementation, uncover facilitators and barriers of quality improvement, and highlight contextual factors that might have influenced implementation. Performance implementation scores were used to rank the villages. Identifying higher- and lower-performing villages highlighted key facilitators and barriers of community-level quality improvement related to support from local leaders, motivation through use of local quality improvement data, and regular education around quality improvement and maternal and newborn health. These findings can be taken formatively in the design of similar interventions in the future.
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Affiliation(s)
- Tara Tancred
- 1 London School of Hygiene & Tropical Medicine, London, UK
| | - Fatuma Manzi
- 2 Ifakara Health Institute, Dar es Salaam, Tanzania
| | | | - Tanya Marchant
- 1 London School of Hygiene & Tropical Medicine, London, UK
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Schleiff M, Balabanova D, Tancred T, Peters D. Development of a global database for health policy and systems research
training opportunities. Ann Glob Health 2016. [DOI: 10.1016/j.aogh.2016.04.361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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21
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Tancred T, Marchant T, Hanson C, Schellenberg J, Manzi F. Birth preparedness and place of birth in Tandahimba district, Tanzania: what women prepare for birth, where they go to deliver, and why. BMC Pregnancy Childbirth 2016; 16:165. [PMID: 27422526 PMCID: PMC4947316 DOI: 10.1186/s12884-016-0945-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [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: 09/17/2015] [Accepted: 06/03/2016] [Indexed: 01/01/2023] Open
Abstract
Background As making preparations for birth and health facility delivery are behaviours linked to positive maternal and newborn health outcomes, we aimed to describe what birth preparations were made, where women delivered, and why. Methods Outcomes were tabulated using data derived from a repeated sample (continuous) quantitative household survey of women aged 13–49 who had given birth in the past year. Insights into why behaviours took place emerged from analysis of in-depth interviews (12) and birth narratives (36) with recently delivered mothers and male partners. Results Five hundred-twenty three women participated in the survey from April 2012–November 2013. Ninety-five percent (496/523) of women made any birth preparations for their last pregnancy. Commonly prepared birth items were cotton gauze (93 %), a plastic cover to deliver on (84 %), gloves (72 %), clean clothes (70 %), and money (42 %). Qualitative data suggest that preparation of items used directly during delivery was perceived as necessary to facilitate good care and prevent disease transmission. Sixty-eight percent of women gave birth at a health facility, 30 % at home, and 2 % on the way to a health facility. Qualitative data suggested that health facility delivery was viewed positively and that women were inclined to go to a health facility because of a perception of: increased education about delivery and birth preparedness; previous health facility delivery; and better availability and accessibility of facilities in recent years. Perceived barriers: were a lack of money; absent health facility staff or poor provider attitudes; women perceiving that they were unable to go to a health facility or arrange transport on their own; or a lack of support of pregnant women from their partners. Conclusions The majority of women made at least some birth preparations and gave birth in a health facility. Functional items needed for birth seem to be given precedence over practices like saving money. As such, maintaining education about the importance of these practices, with an emphasis on emergency preparedness, would be valuable. Alongside education delivered as part of focussed antenatal care, community-based interventions that aim to increase engagement of men in birth preparedness, and support agency among women, are recommended.
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Affiliation(s)
- Tara Tancred
- London School of Hygiene and Tropical Medicine, London, UK.
| | - Tanya Marchant
- London School of Hygiene and Tropical Medicine, London, UK
| | - Claudia Hanson
- London School of Hygiene and Tropical Medicine, London, UK.,Karolinska Institute, Stockholm, Sweden
| | | | - Fatuma Manzi
- Ifakara Health Institute, Dar es Salaam, Tanzania
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Tancred T, Schellenberg J, Marchant T. Using mixed methods to evaluate perceived quality of care in southern Tanzania. Int J Qual Health Care 2016; 28:233-9. [PMID: 26823050 PMCID: PMC4833203 DOI: 10.1093/intqhc/mzw002] [Citation(s) in RCA: 18] [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] [Accepted: 12/30/2015] [Indexed: 11/09/2022] Open
Abstract
Objective To compare perceived quality of maternal and newborn care using quantitative and qualitative methods. Design A continuous household survey (April 2011 to November 2013) and in-depth interviews and birth narratives. Setting Tandahimba district, Tanzania. Participants Women aged 13–49 years who had a birth in the previous 2 years were interviewed in a household survey. Recently delivered mothers and their partners participated in in-depth interviews and birth narratives. Intervention None. Main Outcome Measures Perceived quality of care. Results Quantitative: 1138 women were surveyed and 93% were confident in staff availability and 61% felt that required drugs and equipment would be available. Drinking water was easily accessed by only 60% of respondents using hospitals. Measures of interaction with staff were very positive, but only 51% reported being given time to ask questions. Unexpected out-of-pocket payments were higher in hospitals (49%) and health centres (53%) than in dispensaries (31%). Qualitative data echoed the lack of confidence in facility readiness, out-of-pocket payments and difficulty accessing water, but was divergent in responses about interactions with health staff. More than half described staff interactions that were disrespectful, not polite, or not helpful. Conclusion Both methods produced broadly aligned results on perceived readiness, but divergent results on perceptions about client–staff interactions. Benefits and limitations to both quantitative and qualitative approaches were observed. Using mixed methodologies may prove particularly valuable in capturing the user experience of maternal and newborn health services, where they appear to be little used together.
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Affiliation(s)
- Tara Tancred
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Tanya Marchant
- London School of Hygiene and Tropical Medicine, London, UK
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