Delivery arrangements for health systems in low-income countries: an overview of systematic reviews

Appraisal of umbrella reviews on vaccines

Umbrella reviews are systematic reviews of all systematic reviews on a given question and can provide a higher-level view of current available evidence on broad research topics. Given the importance and possible consequences of the insights derived from umbrella reviews, it is fundamental to ensure accurate, comprehensive reporting and methodological rigor in these papers. Here, we present the potential and limitations of these evolving evidence synthesis tools by looking at umbrella reviews published on vaccine research. Vaccines are essential tools in modern medicine for preventing disease and promoting public health. The scientific literature on vaccines grows rapidly as researchers work to improve existing vaccines and develop new ones. More than half a million scientific papers on vaccines have already been published, including several thousands of systematic reviews that aim to appraise and summarize this growing literature. However, as the published systematic reviews are only able to cover a small proportion of the literature it is important to also provide higher-level evidence syntheses. and discuss further improvements that could be made to integrate evidence on vaccines.

[Evidence synthesis and recommendations: clinical practice guidelines on drug treatment for hypertension in pregnancySíntese de evidências e recomendações: diretrizes de prática clínica para o tratamento farmacológico da hipertensão arterial na gravidez]

Introduction

Hypertensive disorders during pregnancy are a major cause of severe morbidity, long-term disability, and death. Appropriate pharmacological treatment is essential in the management of these disorders.

Objectives

Synthesize the recommendations developed by the World Health Organization (WHO) to improve the quality of care and health outcomes of adults with high blood pressure, and address aspects of how to implement these recommendations.

Methods

A synthesis was conducted of WHO recommendations: drug treatment for severe hypertension in pregnancy and WHO recommendations: drug treatment for non-severe hypertension in pregnancy. The WHO recommendations follow the GRADE methodology (Grading of Recommendations, Assessment, Development, and Evaluation) for the preparation of guidelines, as described in the WHO Handbook for Guideline Development. In addition, a systematic search for studies carried out in the Region of the Americas was conducted in PubMed, Lilacs, Health Systems Evidence, Epistemonikos, and gray literature to identify barriers, facilitators, and implementation strategies.

Results

Four recommendations were formulated for women with hypertensive disorders. Implementation barriers and facilitators were identified, and indicators were created to assess adherence and outcomes.

Conclusions

The formulated recommendations provide guidance on how to approach drug treatment of hypertension in pregnancy, with considerations for implementation in Latin America and the Caribbean.

Healthcare System Sustainability Challenges in Nepal and Opportunities Offered by Alternative Healthcare Delivery Arrangements

ABSTRACT

The burden of chronic diseases in Nepal is increasing due to demographic and epidemiological transitions; alongside the persistent impact of communicable, maternal, newborn, and child health diseases, this critical situation acts as the precursor to rising healthcare costs. Nepal struggles to sustain its healthcare system amidst political instability, pandemics, natural disasters, and slow economic growth, particularly when healthcare funding is mainly dependent on out-of-pocket payments. Nepal requires lower-cost alternative healthcare delivery arrangements to provide high-value care while relieving economic sustainability pressures. Alternative healthcare delivery arrangements have a broad potential scope; they can involve strategic changes in how care is delivered and by whom, or they can also involve the application of information and communication technologies, e.g., telemedicine. This paper highlights the specific challenges to healthcare system sustainability in Nepal and the potential for high-value, lower-cost alternative healthcare delivery models to improve system performance in the longer term.

Digitally Delivered Interventions to Improve Nutrition Behaviors Among Resource-Poor and Ethnic Minority Groups With Type 2 Diabetes: Systematic Review

BACKGROUND

Resource-poor individuals, such as those with a low income, are disproportionately affected by diabetes and unhealthy eating patterns that contribute to poor disease self-management and prognosis. Digitally delivered interventions have the potential to address some of the barriers to healthy eating experienced by this group. However, little is known about their effectiveness in disadvantaged populations.

OBJECTIVE

This systematic review is conducted to assess the effectiveness of digitally delivered interventions in improving nutritional behaviors and nutrition-related health outcomes among disadvantaged people with type 2 diabetes (T2D).

METHODS

MEDLINE complete, Global Health, Embase, CINAHL complete, Informit Health, IEEE Xplore, and Applied Science and Technology Source databases were searched for studies published between 1990 and 2022 on digitally delivered nutrition interventions for disadvantaged people with T2D. Two reviewers independently assessed the studies for eligibility and determined the study quality using the Cochrane Risk-of-Bias Assessment Tool. The Behavioral Change Technique Taxonomy V1 was used to identify behavior change techniques used in the design of interventions.

RESULTS

Of the 2434 identified records, 10 (0.4%), comprising 947 participants, met the eligibility criteria and were included in the review. A total of 2 digital platforms, web and messaging services (eg, SMS text messaging interventions or multimedia messaging service), were used to deliver interventions. Substantial improvements in dietary behaviors were reported in 5 (50%) of the 10 studies, representing improvements in healthier food choices or increases in dietary knowledge and skills or self-efficacy. Of the 10 studies, 7 (70%) examined changes in blood glucose levels, of which 4 (57%) out of 7 achieved significant decreases in hemoglobin A1C levels ranging from 0.3% to 1.8%. The most frequently identified behavior change techniques across all studies were instruction on how to perform the behavior, information about health consequences, and social support.

CONCLUSIONS

This review provided some support for the efficacy of digitally delivered interventions in improving healthy eating behaviors in disadvantaged people with T2D, an essential dietary prerequisite for changes in clinical metabolic parameters. Further research is needed into how disadvantaged people with T2D may benefit more from digital approaches and to identify the specific features of effective digital interventions for supporting healthy behaviors among disadvantaged populations.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42020149844; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=149844.

Mobile phone use for pregnancy-related healthcare utilization and its association with optimum antenatal care and hospital delivery in Bangladesh

Pregnancy-related healthcare utilization is inadequate in Bangladesh, where more than half of pregnant women do not receive optimum number of antenatal care (ANC) visits or do not deliver child in hospitals. Mobile phone use could improve such healthcare utilization; however, limited evidence exists in Bangladesh. We investigated the pattern, trends, and factors associated with mobile phone use for pregnancy-related healthcare and how this can impact at least 4 ANC visits and hospital delivery in the country. We analyzed cross-sectional data from Bangladesh Demographic and Health Survey (BDHS) 2014 (n = 4,465) and 2017-18 (n = 4,903). Only 28.5% and 26.6% women reported using mobile phones for pregnancy-related causes in 2014 and 2017-18, respectively. Majority of the time, women used mobile phones to seek information or to contact service providers. In both survey periods, women with a higher education level, more educated husbands, a higher household wealth index, and residence in certain administrative divisions had greater likelihoods of using mobile phones for pregnancy-related causes. In BDHS 2014, proportions of at least 4 ANC and hospital delivery were, respectively, 43.3% and 57.0% among users, and 26.4% and 31.2% among non-users. In adjusted analysis, the odds of utilizing at least 4 ANC were 1.6 (95% confidence interval (CI): 1.4-1.9) in BDHS 2014 and 1.4 (95% CI: 1.3-1.7) in BDHS 2017-18 among users. Similarly, in BDHS 2017-18, proportions of at least 4 ANC and hospital delivery were, respectively, 59.1% and 63.8% among users, and 42.8% and 45.1% among non-users. The adjusted odds of hospital delivery were also high, 2.0 (95% CI: 1.7-2.4) in BDHS 2014 and 1.5 (95% CI: 1.3-1.8) in BDHS 2017-18. Women with history of using mobile phones for pregnancy-related causes were more likely to utilize at least 4 ANC visits and deliver in health facilities, however, most women were not using mobile phones for that.

Self-reported continuity and coordination of antenatal care and its association with obstetric near miss in Uasin Gishu county, Kenya

BACKGROUND

Continuity and coordination of care are core principles of high-quality primary health care. Optimising continuity and coordination improves maternal satisfaction. However, their association with morbidity and mortality outcomes is unclear. The obstetric near-miss approach can be used to investigate whether continuity and coordination influences the occurrence of a severe maternal outcome.

AIM

To compare self-reported continuity and coordination of care between obstetric near-miss survivors and those without near miss during pregnancy, delivery and postpartum.

SETTING

Uasin Gishu county, Rift Valley region, Kenya.

METHODS

A cross-sectional survey targeting 340 postnatal mothers. Continuity of care index (COCI) and modified continuity of care index (MCCI) were used to estimate longitudinal continuity. The Likert scale was administered to measure perceived continuity and coordination of care. Mann-Whitney U test and binomial logistic regression were used for hypothesis testing.

RESULTS

COCI and MCCI were lower among near-miss survivors (COCI = 0.80, p = 0.0026), (MCCI = 0.62, p = 0.034). Near-miss survivors scored lower on items assessing coordination between a higher-level provider and usual antenatal clinic (mean = 3.6, p = 0.006) and general coordination of care during pregnancy (mean = 3.9, p = 0.019). Presence of a non-life-threatening morbidity in pregnancy was associated with occurrence of near miss (aOR = 4.34, p = 0.001).

CONCLUSION

Near-miss survivors scored lower on longitudinal continuity and coordination of care across levels. Further research should focus on strengthening coordination, determining the optimal level of longitudinal continuity and improving systems for early identification and management of morbidities in pregnancy.Contribution: The results of this study show that while longitudinal and relational COC is important during the antenatal period, the presence of a non-life-threatening condition in pregnancy remains the most important predictor of the occurrence of a near miss.

Interventions for promoting and optimizing breastfeeding practices: An overview of systematic review

Background

Optimal breastfeeding (BF) practices are essential for child survival and proper growth and development. The purpose of this overview is to evaluate the effectiveness of different interventions for promoting and optimizing breastfeeding.

Methods

We included systematic reviews (SRs) [including trials from Low-Income (LICs) and Low Middle-Income countries (LMICs)] that have evaluated the effect of various interventions for promoting and optimizing breastfeeding and excluded non-systematic reviews, and SRs based on observational studies. We searched various electronic databases. We followed the standard methodology as suggested by the Cochrane Handbook for Systematic Reviews of Interventions. Two sets of reviewers undertook screening followed by data extraction and assessment of the methodological quality of included SRs.

Result

We identified and screened 1,002 Cochrane SRs and included six SRs in this overview. Included SRs reported only two of the primary outcomes, early initiation of breastfeeding (EIBF) and/or exclusive breastfeeding (EBF). None of the included SR reported continued BF up to 2 years of age. The results were evaluated using two major comparisons groups: BF intervention against routine care and one type of BF intervention vs. other types of BF intervention. Overall results from included SRs showed that there were improvements in the rates of EIBF and EBF among women who received BF intervention such as BF education sessions and support compared to those women who received only standard care. However, BF intervention via mobile devices showed no improvements. In Target Client Communication (TCC) via mobile devices intervention group, no significant improvements were reported in BF practices, and also the reported evidence was of very low certainty.

Conclusion

Community Based Intervention Packages (CBIP) delivered to pregnant and reproductive-age women during their Antenatal care (ANC) and/or Postnatal care (PNC) periods by Ancillary Nurse-Midwives reported the highest improvement in EIBF compared to women who received standard care. However, insufficient evidence was reported to suggest that BF intervention showed improvements in EBF in both the comparison groups. This overview highlighted the gaps in primary research regarding the uncertainty about the settings such as LICs or LMICs, lack of evidence from LMICs, and also identified gaps in the availability of reliable up-to-date SRs on the effects of several BF interventions to promote and optimize practices.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020174998, PROSPERO [CRD42020174998].

Situational analysis of the quality of palliative care services across India: a cross-sectional survey

Objective

Palliative care services in India were established in the 1980s but there is no detailed up-to-date knowledge about the quality-of-service provision nationally. We aim to describe the current quality of palliative care provision in India, as measured against nationally adopted standards.

Method

A digital survey adapted from the Indian Association of Palliative Care Standards Audit Tool was administered to 250 palliative care centres.

Results

Two hundred and twenty-three (89%) palliative care centres participated - 26.4% were government-run, while the rest include non-governmental organisations, private hospitals, community-led initiatives and hospices. About 200 centres 'often' or 'always' fulfilled 16/21 desirable criteria; however, only 2/15 essential criteria were 'often' or 'always' fulfilled. Only 5.8% provide uninterrupted access to oral morphine.

Significance of the results

Palliative care centres in India are falling short of meeting the essential quality standards, indicating the urgent need for new initiatives to drive national change.

Using and improving the PHISICC paper-based tools in the health facility laboratories: Examples of Human Centered Design taking systems thinking into practice, in Côte d'Ivoire and Nigeria

Background

Health workers in low- and middle-income countries are increasingly demanded to collect more and more data to report them to higher levels of the health information system (HIS), in detriment of useful data for clinical and public health decision-making, potentially compromising the quality of their health care provison. In order to support health workers' decision-making, we engaged with partners in Côte d'Ivoire, Mozambique and Nigeria in a research project to conceive, design, produce, implement and test paper-based health information tools: the PHISICC tools. Our aim was to understand the use of PHISICC tools by health workers and to improve them based on their feedback.

Methods

The design Health Facility Laboratories (HF Labs) in Côte d'Ivoire and in Nigeria were set up after months of use of PHISICC tools. Activities were structured in three phases or 'sprints' of co-creative research. We used a transdisciplinary approach, including anthropology and Human Centered Design (HCD), observations, shadowing, structured interviews and co-creation.

Results

Health workers appreciated the standardization of the tools across different health care areas, with a common visual language that optimized use. Several design issues were raised, in terms of formats and contents. They strongly appreciated how the PHISICC registers guided their clinical decision-making and how it facilitated tallying and counting for monthly reporting. However, adherence to new procedures was not universal. The co-creation sessions resulted in modifications to the PHISICC tools of out-patient care and postnatal care.

Discussion

Although health systems and systemic thinking allowed the teams to embrace complexity, it was the HCD approach that actually produced a shift in researchers' mind-set: from HIS as data management tools to HIS as quality of care instruments. HCD allowed navigating the complexity of health systems interventions due to its capacity to operate change: it not only allowed us to understand how the PHISICC tools were used but also how to further improve them. In the absence of (or even with) an analytical health systems framework, HCD approaches can work in real-life situations for the ideation, testing and implementation of interventions to improve health systems and health status outcomes.

Effects of aerobic, strength, and combined training during pregnancy in the blood pressure: A systematic review and meta-analysis

Gestational hypertension can lead to fetal complications, and, if untreated, high blood pressure during pregnancy may cause eclampsia and even death in the mother and fetus. Exercise is a strategy for preventing blood pressure disorders. There is little knowledge about the physiological impacts of different physical types of training on blood pressure during pregnancy. For that, this meta-analysis aimed to compare the effects of different physical exercise modalities (i.e., aerobic training-AT, strength training-ST, and combined training-AT + ST) on systolic blood pressure (SBP) and diastolic blood pressure (DBP) of pregnant women. A search was performed on PUBMED, LILACS, CINAHL, Sport discus, EMBASE, SCOPUS, and Cochrane Central Register of Controlled Trials to identify researchers. From 3,450 studies, 20 and 19 were included in the qualitative and quantitative analyses. AT studies presented a medium effect size (ES) on SBP [-0.29 (-2.95 to 2.36) p = 0.83], with substantial heterogeneity (I2 = 64%), and had a large impact on DBP [-1.34 (-2.98 to 0.30) p = 0.11], with moderate heterogeneity (I2 = 30%). ST researchers showed a large ES on SBP [-1.09 (-3.66 to 1.49) p = 0.41], with a reduced heterogeneity (I2 = 0%), and a medium ES on DBP [-0.26 (-2.77 to 2.19) p = 0.83] with moderate heterogeneity (I2 = 38%). AT + ST studies had a large ES on SBP [-1.69 (-3.88 to 0.49) p = 0.13] and DBP [-01.29 (-2.26 to 0.31) p = 0.01] with considerable (I2 = 83%) and moderate heterogeneity (I2 = 47%), respectively. These findings are essential for developing new research protocols to avoid gestational hypertension and preeclampsia. AT + ST had a large impact on the SBP and DBP reduction; however, there is a need for more similar procedures to reduce heterogeneity between studies, promoting consensual results. Systematic Review Registration: [PROSPERO], identifier [CRD42021256509].

Biopsychosocial Factors for Chronicity in Individuals with Non-Specific Low Back Pain: An Umbrella Review

Low back pain (LBP) is a global and disabling problem. A considerable number of systematic reviews published over the past decade have reported a range of factors that increase the risk of chronicity due to LBP. This study summarizes up-to-date and high-level research evidence on the biopsychosocial prognostic factors of outcomes in adults with non-specific low back pain at follow-up. An umbrella review was carried out. PubMed, the Cochrane Database of Systematic Reviews, Web of Science, PsycINFO, CINAHL Plus and PEDro were searched for studies published between 1 January 2008 and 20 March 2020. Two reviewers independently screened abstracts and full texts, extracted data and assessed review quality. Fifteen systematic reviews met the eligibility criteria; all were deemed reliable according to our criteria. There were five prognostic factors with consistent evidence of association with poor acute-subacute LBP outcomes in the long term (high levels of pain intensity and disability, high emotional distress, negative recovery expectations and high physical demands at work), as well as one factor with consistent evidence of no association (low education levels). For mixed-duration LBP, there was one predictor consistently associated with poor outcomes in the long term (high pain catastrophism). We observed insufficient evidence to synthesize social factors as well as to fully assess predictors in the chronic phase of LBP. This study provides consistent evidence of the predictive value of biological and psychological factors for LBP outcomes in the long term. The identified prognostic factors should be considered for inclusion into low back pain explanatory models.

Reporting of health equity considerations in equity-relevant observational studies: Protocol for a systematic assessment

Background: The mitigation of unfair and avoidable differences in health is an increasing global priority. Observational studies including cohort, cross-sectional and case-control studies tend to report social determinants of health which could inform evidence syntheses on health equity and social justice. However, the extent of reporting and analysis of equity in equity-relevant observational studies is unknown. Methods: We define studies which report outcomes for populations at risk of experiencing inequities as “equity-relevant”. Using a random sampling technique we will identify 320 equity-relevant observational studies published between 1 January 2020 to 27 April 2022 by searching the MEDLINE database. We will stratify sampling by 1) studies in high-income countries (HIC) and low- and middle-income countries (LMIC) according to the World Bank classification, 2) studies focused on COVID and those which are not, 3) studies focused on populations at risk of experiencing inequities and those on general populations that stratify their analyses. We will use the PROGRESS framework which stands for place of residence, race or ethnicity, occupation, gender or sex, religion, education, socioeconomic status, social capital, to identify dimensions where inequities may exist. Using a previously developed data extraction form we will pilot-test on eligible studies and revise as applicable. Conclusions: The proposed methodological assessment of reporting will allow us to systematically understand the current reporting and analysis practices for health equity in observational studies. The findings of this study will help inform the development of the equity extension for the STROBE (Strengthening the Reporting of Observational studies in Epidemiology) reporting guidelines.

mHealth Phone Intervention to Reduce Maternal Deaths and Morbidity in Cameroon: Protocol for Translational Adaptation

Purpose

The purpose of this NIH-funded protocol is to adapt (Aim 1) and pilot test (Aim 2) an mHealth intervention to improve maternal and child health in Cameroon. We will adapt the 24/7 University of Alabama at Birmingham Medical Information Service via Telephone (MIST) provider support system to mMIST (mobile MIST) for peripheral providers who provide healthcare to pregnant and postpartum women and newborns in Cameroon.

Methods

In Aim 1, we apply qualitative and participatory methods (in-depth interviews and focus groups with key stakeholders) to inform the adaptation of mMIST for use in Cameroon. We use the sequential phases of the ADAPT-ITT framework to iteratively adapt mMIST incorporating qualitative findings and tailoring for local contexts. In Aim 2, we test the adapted intervention for feasibility and acceptability in Ndop, Cameroon.

Results

This study is ongoing at the time that this protocol is published.

Conclusion

The adaptation, refinement, and pilot testing of mMIST will be used to inform a larger-scale stepped wedged cluster randomized controlled effectiveness trial. If successful, this mHealth intervention could be a powerful tool enabling providers in low-resource settings to deliver improved pregnancy care, thereby reducing maternal and fetal deaths.

Content validation of educational materials on maternal depression in Nigeria

Background

This study describes the content validation process of the already developed English and Yoruba (poster and leaflet) and Yoruba (song) maternal depression educational materials in Nigeria.

Methods

This study is a cross sectional study which is a part of a larger study on training and supervision of Primary health care workers. Study utilized health professionals’ judgement for content validation, and maternal-child health clients’ evaluation for face validation with the use of Suitability Assessment of Materials (SAM). Six bilingual professionals validated both English and Yoruba version of materials (Song has only Yoruba version) and 50 clients evaluated each Yoruba material. Validity Index was calculated by formula and inter-rater agreement using intra-class coefficient (ICC) was analyzed on Professionals’ ratings. ICC, ‵t′ test and Pearson correlation were analyzed on professionals’ rating versus randomly selected six clients’ rating. Descriptive statistics, and fisher exact test were used for other statistical analysis with SPSS version 25.

Results

The mean age of the professionals for poster was 44.3 ± 6.0 years, for leaflet 39.8 ± 7.2 years, for song 43.8 ± 8.4 years. For maternal child health clients, mean age is: 30.7 ± 5.4 years for poster; 31.3 ± 5.2 for leaflet and 29.0 ± 5.1 for song. Outcomes of bilingual professionals’ validation are validity index: English {leaflet (0.94), poster (0.94)}, and Yoruba {leaflet (0.94) poster (0.94) and song (1.00)}. More than 80% clients rated the suitability of each material as superior. There is no significant relationship between clients’ sociodemographic characteristics and their ratings across content, literacy demand and cultural appropriateness domains of the three materials on fisher exact test. The inter-rater agreement among the professionals is excellent on leaflet and song ICC > 0.8, but it is weak on the poster ICC < 0.6. There is no inter-rater agreement on all the three Yoruba materials, but a negative linear correlation was found on the leaflet between the professionals’ ratings and the randomly selected clients’ ratings. ‵t′ test found no statistical difference in the ratings of the professionals and clients only on song material.

Conclusion

This study shows the process of validation of the English and Yoruba versions of the educational materials. This process should be leveraged in the content validation of other maternal-child health education materials in Africa.

How effects on health equity are assessed in systematic reviews of interventions

BACKGROUND

Enhancing health equity is endorsed in the Sustainable Development Goals. The failure of systematic reviews to consider potential differences in effects across equity factors is cited by decision-makers as a limitation to their ability to inform policy and program decisions.  OBJECTIVES: To explore what methods systematic reviewers use to consider health equity in systematic reviews of effectiveness.

SEARCH METHODS

We searched the following databases up to 26 February 2021: MEDLINE, PsycINFO, the Cochrane Methodology Register, CINAHL, Education Resources Information Center, Education Abstracts, Criminal Justice Abstracts, Hein Index to Foreign Legal Periodicals, PAIS International, Social Services Abstracts, Sociological Abstracts, Digital Dissertations and the Health Technology Assessment Database. We searched SCOPUS to identify articles that cited any of the included studies on 10 June 10 2021. We contacted authors and searched the reference lists of included studies to identify additional potentially relevant studies.

SELECTION CRITERIA

We included empirical studies of cohorts of systematic reviews that assessed methods for measuring effects on health inequalities. We define health inequalities as unfair and avoidable differences across socially stratifying factors that limit opportunities for health. We operationalised this by assessing studies which evaluated differences in health across any component of the PROGRESS-Plus acronym, which stands for Place of residence, Race/ethnicity/culture/language, Occupation, Gender or sex, Religion, Education, Socioeconomic status, Social capital. "Plus" stands for other factors associated with discrimination, exclusion, marginalisation or vulnerability such as personal characteristics (e.g. age, disability), relationships that limit opportunities for health (e.g. children in a household with parents who smoke) or environmental situations which provide limited control of opportunities for health (e.g. school food environment).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data using a pre-tested form. Risk of bias was appraised for included studies according to the potential for bias in selection and detection of systematic reviews.  MAIN RESULTS: In total, 48,814 studies were identified and the titles and abstracts were screened in duplicate. In this updated review, we identified an additional 124 methodological studies published in the 10 years since the first version of this review, which included 34 studies. Thus, 158 methodological studies met our criteria for inclusion. The methods used by these studies focused on evidence relevant to populations experiencing health inequity (108 out of 158 studies), assess subgroup analysis across PROGRESS-Plus (26 out of 158 studies), assess analysis of a gradient in effect across PROGRESS-Plus (2 out of 158 studies) or use a combination of subgroup analysis and focused approaches (20 out of 158 studies). The most common PROGRESS-Plus factors assessed were age (43 studies), socioeconomic status in 35 studies, low- and middle-income countries in 24 studies, gender or sex in 22 studies, race or ethnicity in 17 studies, and four studies assessed multiple factors across which health inequity may exist. Only 16 studies provided a definition of health inequity. Five methodological approaches to consider health equity in systematic reviews of effectiveness were identified: 1) descriptive assessment of reporting and analysis in systematic reviews (140 of 158 studies used a type of descriptive method); 2) descriptive assessment of reporting and analysis in original trials (50 studies); 3) analytic approaches which assessed differential effects across one or more PROGRESS-Plus factors (16 studies); 4) applicability assessment (25 studies) and 5) stakeholder engagement (28 studies), which is a new finding in this update and examines the appraisal of whether relevant stakeholders with lived experience of health inequity were included in the design of systematic reviews or design and delivery of interventions. Reporting for both approaches (analytic and applicability) lacked transparency and was insufficiently detailed to enable the assessment of credibility.

AUTHORS' CONCLUSIONS

There is a need for improvement in conceptual clarity about the definition of health equity, describing sufficient detail about analytic approaches (including subgroup analyses) and transparent reporting of judgments required for applicability assessments in order to consider health equity in systematic reviews of effectiveness.

Health service providers' perspectives on the influence of modern health systems on adolescents' sexual health practices in Umguza and Mberengwa districts of Zimbabwe

BACKGROUND

Health service providers play a significant role in crafting and implementing health policies and programs that manage adolescent sexual health-related issues at different health system levels. These influence adolescent sexual behaviours and practices.

AIM

This study explored the roles of health service providers in managing adolescent sexual issues and how this impacts their sexual behaviours and practices. The study further probed the health service providers on how the indigenous health system could be integrated into the modern health system for effective management of adolescent sexual health related issues.

METHODS

A qualitative cross-sectional survey was conducted on purposively selected health service providers in health facilities in Mberengwa and Umguza districts. Data was collected using unstructured interviews that were recorded, transcribed verbatim, and thematically analysed. Findings were presented as clearly defined as superordinate and subordinate themes.

RESULTS

A total of five superordinate themes and 19 subordinate themes emerged from the interrogated data. The superordinate themes were: overview of adolescent sexual health issues, role of modern health system in adolescent sexual health issues, challenges encountered, indigenous health system factors that could be factored into modern health systems, and strategies to foster the integration of indigenous health system and modern health system. The subordinate themes explored in-depth the findings of the key stakeholders under the five superordinate themes.

CONCLUSIONS

From the findings, it can be concluded that health service providers play an essential role in shaping and providing adolescent sexual health services that adolescents utilise despite challenges that have reduced demand for these services. Therefore, there is a need to point out that there is a window of opportunity to foster collaborations between the indigenous health system and the modern health system as they strive to serve the adolescents to the best of their ability though in different contextual settings.

A one-stop shop model for improved efficiency of pre-exposure prophylaxis delivery in public clinics in western Kenya: a mixed methods implementation science study

INTRODUCTION

In public clinics in Kenya, separate, sequential delivery of the component services of pre-exposure prophylaxis (PrEP) (e.g. HIV testing, counselling, and dispensing) creates long wait times that hinder clients' ability and desire to access and continue PrEP. We conducted a mixed methods study in four public clinics in western Kenya to identify strategies for operationalizing a one-stop shop (OSS) model and evaluate whether this model could improve client wait time and care acceptability among clients and providers without negatively impacting uptake or continuation.

METHODS

From January 2020 through November 2020, we collected and analysed 47 time-and-motion observations using Mann-Whitney U tests, 29 provider and client interviews, 68 technical assistance reports, and clinic flow maps from intervention clinics. We used controlled interrupted time series (cITS) to compare trends in PrEP initiation and on-time returns from a 12-month pre-intervention period (January-December 2019) to an 8-month post-period (January-November 2020, excluding a 3-month COVID-19 wash-out period) at intervention and control clinics.

RESULTS

From the pre- to post-period, median client wait time at intervention clinics dropped significantly from 31 to 6 minutes (p = 0.02), while median provider contact time remained around 23 minutes (p = 0.4). Intervention clinics achieved efficiency gains by moving PrEP delivery to lower volume departments, moving steps closer together (e.g. relocating supplies; cross-training and task-shifting), and differentiating clients based on the subset of services needed. Clients and providers found the OSS model highly acceptable and additionally identified increased privacy, reduced stigma, and higher quality client-provider interactions as benefits of the model. From the pre- to post-period, average monthly initiations at intervention and control clinics increased by 6 and 2.3, respectively, and percent of expected follow-up visits occurring on time decreased by 18% and 26%, respectively; cITS analysis of PrEP initiations (n = 1227) and follow-up visits (n = 2696) revealed no significant difference between intervention and control clinics in terms of trends in PrEP initiation and on-time returns (all p>0.05).

CONCLUSIONS

An OSS model significantly improved client wait time and care acceptability without negatively impacting initiations or continuations, thus highlighting opportunities to improve the efficiency of PrEP delivery efficiency and client-centredness.

Epidemiologic characteristics and pre-hospital care of traumatic injuries during the COVID-19 pandemic in an emerging and developing country: A single tertiary centre experience

BACKGROUND

Pre-hospital care has been shown to reduce the mortality in trauma patients. The present study is an attempt to identify the status of pre-hospital orthopaedic trauma care in developing countries during COVID-19 pandemic.

METHODS

This was a prospective observational study carried out in a tertiary care setup from March 25th^, 2020 to January 31st^, 2021. All the data pertaining to the traumatic injuries including demographic details and epidemiologic characteristics were recorded in an electronic database.

RESULTS

A total of 1044 patients were included in the study for evaluation. The mean age was 35.24 ± 19.84 years. There were 873 males and 171 females. A total of 748 presented from nearby states, with 401 being the referrals and 347 cases coming directly to hospital. A total of 141 open fractures presented directly and 269 were referred from nearby states. Out of 269 cases of open fractures, only 67 and 139 were given intravenous antibiotics and had wound dressing done respectively at the periphery site. A total of 125, 112, 92 and 84 patients were received without traction/splintage, intravenous fluids, dose of analgesics and recording of vitals respectively. Delay from injury to presentation in emergency/administration of antibiotic (Hours) was 7.06. Road side accidents were main cause comprising of 52.58% cases. Gustilo Anderson classification grade-2 comprised of majority of the open fractures (51.63%). Lower limb fractures comprised of majority of the injuries (70.59%). Majority were adults and conservative management was the most common mode of treatment. A total of 197 and 265 patients had associated head injuries and blunt trauma chest/blunt trauma abdomen respectively.

CONCLUSION

Emphasizing on pre-hospital care measures, with special focus on co-ordination between primary, secondary and tertiary health care facilities is the need of the hour and can prevent additional morbidities, avoiding overburden of the already compromised healthcare centres.

Acute gastroenteritis and the usage pattern of antibiotics and traditional herbal medications for its management in a Nigerian community

Acute gastroenteritis (AGE) is the highest cause of mortality worldwide in children under the age of 5 years, with the highest mortalities occurring in low-to-middle income countries. Treatment can involve use of unregulated herbal medication and antibiotics. A cross sectional study was carried out to investigate the use of antibiotics and traditional herbal medications in the management of AGE among Yòrùbá-speaking communities in Kwara State, Nigeria. Our findings suggest habitual use of antibiotics (54.6%) and herbal medication (42.5%) in the management of AGE with high levels of self-prescription of antibiotics (21.7%) and herbal medications (36.2%) within the community. Ethanolic extracts of selected herbal plants reported (i.e. Aristolochia ringens, Azadirachta indica, Chromolaena odorata, Etanda Africana, Ficus capensis, Ficus vogelii, Mangifera indica, Momordica charantia, Ocimum gratisimum, Senna alata, Sorghum bicolor and Vernonia amygdalina) were investigated for antibacterial properties, using bacteria known to be causative agents of AGE. Our findings showed that, with exception of Ficus vogelii, which enhanced bacterial growth, the plant extracts reported all showed some antibacterial activity. We further discuss our findings within a regulatory context, with the aim to guide the use of traditional and herbal medication in low-to medium income countries (LMICs) and reduce the potential risks associated with the development of antimicrobial resistance.

Intrinsic capacity and its associations with incident dependence and mortality in 10/66 Dementia Research Group studies in Latin America, India, and China: A population-based cohort study

BACKGROUND

The World Health Organization (WHO) has reframed health and healthcare for older people around achieving the goal of healthy ageing. The recent WHO Integrated Care for Older People (ICOPE) guidelines focus on maintaining intrinsic capacity, i.e., addressing declines in neuromusculoskeletal, vitality, sensory, cognitive, psychological, and continence domains, aiming to prevent or delay the onset of dependence. The target group with 1 or more declines in intrinsic capacity (DICs) is broad, and implementation may be challenging in less-resourced settings. We aimed to inform planning by assessing intrinsic capacity prevalence, by characterising the target group, and by validating the general approach-testing hypotheses that DIC was consistently associated with higher risks of incident dependence and death.

METHODS AND FINDINGS

We conducted population-based cohort studies (baseline, 2003-2007) in urban sites in Cuba, Dominican Republic, Puerto Rico, and Venezuela, and rural and urban sites in Peru, Mexico, India, and China. Door-knocking identified eligible participants, aged 65 years and over and normally resident in each geographically defined catchment area. Sociodemographic, behaviour and lifestyle, health, and healthcare utilisation and cost questionnaires, and physical assessments were administered to all participants, with incident dependence and mortality ascertained 3 to 5 years later (2008-2010). In 12 sites in 8 countries, 17,031 participants were surveyed at baseline. Overall mean age was 74.2 years, range of means by site 71.3-76.3 years; 62.4% were female, range 53.4%-67.3%. At baseline, only 30% retained full capacity across all domains. The proportion retaining capacity fell sharply with increasing age, and declines affecting multiple domains were more common. Poverty, morbidity (particularly dementia, depression, and stroke), and disability were concentrated among those with DIC, although only 10% were frail, and a further 9% had needs for care. Hypertension and lifestyle risk factors for chronic disease, and healthcare utilisation and costs, were more evenly distributed in the population. In total, 15,901 participants were included in the mortality cohort (2,602 deaths/53,911 person-years of follow-up), and 12,939 participants in the dependence cohort (1,896 incident cases/38,320 person-years). One or more DICs strongly and independently predicted incident dependence (pooled adjusted subhazard ratio 1.91, 95% CI 1.69-2.17) and death (pooled adjusted hazard ratio 1.66, 95% CI 1.49-1.85). Relative risks were higher for those who were frail, but were also substantially elevated for the much larger sub-groups yet to become frail. Mortality was mainly concentrated in the frail and dependent sub-groups. The main limitations were potential for DIC exposure misclassification and attrition bias.

CONCLUSIONS

In this study we observed a high prevalence of DICs, particularly in older age groups. Those affected had substantially increased risks of dependence and death. Most needs for care arose in those with DIC yet to become frail. Our findings provide some support for the strategy of optimising intrinsic capacity in pursuit of healthy ageing. Implementation at scale requires community-based screening and assessment, and a stepped-care intervention approach, with redefined roles for community healthcare workers and efforts to engage, train, and support them in these tasks. ICOPE might be usefully integrated into community programmes for detecting and case managing chronic diseases including hypertension and diabetes.

Bilateral pelvic kidneys with upper pole fusion and malrotation: a case report and review of the literature

BACKGROUND

The incidence of ectopic kidneys is 1:12,000 clinically and 1:900 postmortem. Patients with pelvic mal-rotated kidneys are more susceptible to recurrent urinary tract infections, recurrent renal stones, and renal injury. Fusion of the kidney lower poles is relatively common compared to other types of renal anomalies.

CASE PRESENTATION

We present the case of a 36-year-old Sudanese female patient who presented with a long history of recurrent urinary tract infections unresponsive to antibiotics. Ultrasound scan revealed bilateral pelvic kidneys. Computed tomography (CT) urography confirmed bilateral ectopic fused kidneys, with the left kidney mal-rotated (renal pelvis facing upwards and laterally). Kidney infection secondary to vesicoureteral reflux was diagnosed. Antibiotics were prescribed according to culture and sensitivity. The patient responded well to ciprofloxacin.

CONCLUSION

A history of recurrent urinary tract infections without an apparent cause is highly suggestive of renal anomaly and should be investigated expediently. Ultrasonography or CT imaging may be utilized to aid in diagnosis. Early recognition may help prevent the high risk of end-stage renal failure associated with anomalies.

Developing a Common Understanding of Networks of Care through a Scoping Study

The phrase "Networks of Care" seems familiar but remains poorly defined. A health system that exemplifies effective Networks of Care (NOC) purposefully and effectively interconnects service delivery touch points within a catchment area to fill critical service gaps and create continuity in patient care. To more fully elaborate the concept of Networks of Care, we conducted a multi-method scoping study that included a literature review, stakeholder interviews, and descriptive case studies from five low- and middle-income countries. Our extended definition of a Network of Care features four overlapping and interdependent domains of activity at multiple levels of health systems, characterized by: 1) Agreement and Enabling Environment, 2) Operational Standards, 3) Quality, Efficiency and Responsibility, and 4) Learning and Adaptation. There are a series of key interrelated themes within each domain. Creating a common understanding of what characterizes and fosters an effective Network of Care can drive the evolution and strengthening of national health programs, especially those incorporating universal health coverage and promoting comprehensive care and integrated services. An understanding of the Networks of Care model can help guide efforts to move health service delivery toward goals that can benefit a diversity of stakeholders, including a variety of health system actors, such as health care workers, users of health systems, and the wider community at large. It can also contribute to improving poor health outcomes and reducing waste originating from fragmented services and lack of access.

Nudge strategies to improve healthcare providers' implementation of evidence-based guidelines, policies and practices: a systematic review of trials included within Cochrane systematic reviews

BACKGROUND

Nudge interventions are those that seek to modify the social and physical environment to enhance capacity for subconscious behaviours that align with the intrinsic values of an individual, without actively restricting options. This study sought to describe the application and effects of nudge strategies on clinician implementation of health-related guidelines, policies and practices within studies included in relevant Cochrane systematic reviews.

METHODS

As there is varied terminology used to describe nudge, this study examined studies within relevant systematic reviews. A two-stage screening process was undertaken where, firstly, all systematic reviews published in the Cochrane Library between 2016 and 2018 were screened to identify reviews that included quantitative studies to improve implementation of guidelines among healthcare providers. Secondly, individual studies within relevant systematic reviews were included if they were (i) randomised controlled trials (RCTs), (ii) included a nudge strategy in at least one intervention arm, and (iii) explicitly aimed to improve clinician implementation behaviour. We categorised nudge strategies into priming, salience and affect, default, incentives, commitment and ego, and norms and messenger based on the Mindspace framework.

SYNTHESIS

The number and percentage of trials using each nudge strategy was calculated. Due to substantial heterogeneity, we did not undertake a meta-analysis. Instead, we calculated within-study point estimates and 95% confidence intervals, and used a vote-counting approach to explore effects.

RESULTS

Seven reviews including 42 trials reporting on 57 outcomes were included. The most common nudge strategy was priming (69%), then norms and messenger (40%). Of the 57 outcomes, 86% had an effect on clinician behaviour in the hypothesised direction, and 53% of those were statistically significant. For continuous outcomes, the median effect size was 0.39 (0.22, 0.45), while for dichotomous outcomes the median Odds Ratio was 1.62 (1.13, 2.76).

CONCLUSIONS

This review of 42 RCTs included in Cochrane systematic reviews found that the impact of nudge strategies on clinician behaviour was at least comparable to other interventions targeting implementation of evidence-based guidelines. While uncertainty remains, the review provides justification for ongoing investigation of the evaluation and application of nudge interventions to support provider behaviour change.

TRIAL REGISTRATION

This review was not prospectively registered.

Access to primary healthcare services and associated factors in urban slums in Nairobi-Kenya

Background

Access to primary healthcare is crucial for the delivery of Kenya’s universal health coverage policy. However, disparities in healthcare have proved to be the biggest challenge for implementing primary care in poor-urban resource settings. In this study, we assessed the level of access to primary healthcare services and associated factors in urban slums in Nairobi-Kenya.

Methods

The data were drawn from the Lown scholars’ study of 300 randomly selected households in Viwandani slums (Nairobi, Kenya), between June and July 2018. Access to primary care was measured using Penchansky and Thomas’ model. Access index was constructed using principal component analysis and recorded into tertiles with categories labeled as poor, moderate, and highest. Generalized ordinal logistic regression analysis was used to determine the factors associated with access to primary care. The adjusted odds ratios (AOR) and 95% confidence intervals were used to interpret the strength of associations.

Results

The odds of being in the highest access tertile versus the combined categories of lowest and moderate access tertile were three times higher for males than female-headed households (AOR 3.05 [95% CI 1.47–6.37]; p < .05). Households with an average quarterly out-of-pocket healthcare expenditure of ≥USD 30 had significantly lower odds of being in the highest versus combined categories of lowest and moderate access tertile compared to those spending ≤ USD 5 (AOR 0.36 [95% CI 0.18–0.74]; p < .05). Households that sought primary care from private facilities had significantly higher odds of being in the highest versus combined categories of lowest and moderate access tertiles compared to those who sought care from public facilities (AOR 6.64 [95% CI 3.67–12.01]; p < .001).

Conclusion

In Nairobi slums in Kenya, living in a female-headed household, seeking care from a public facility, and paying out-of-pocket for healthcare are significantly associated with low access to primary care. Therefore, the design of the UHC program in this setting should prioritize quality improvement in public health facilities and focus on policies that encourage economic empowerment of female-headed households to improve access to primary healthcare.

Defining and classifying public health systems: a critical interpretive synthesis

Background

The introduction of the determinants of health has caused a shift towards understanding health from a holistic perspective as well as increased recognition of public health’s contributions to the health of the population. Several frameworks exist to conceptualise healthcare systems, highlighting the stark contrast of frameworks unique to public health systems. The objectives of this study were to define public health systems and assess differences between healthcare systems and public health systems within established health systems frameworks.

Methods

A critical interpretive synthesis was conducted. Databases searched included EBSCOhost, OVID, Scholars Portal, Web of Science, Cochrane Library and Health Systems Evidence. Data extraction, coding and analysis followed a best-fit framework analysis method. Initial codes were based on a current leading health systems and policy classification scheme – health systems arrangements (governance, financial and delivery arrangements).

Results

A total of 5933 unique documents were identified and 67 were included in the analysis. Definitions of public health and public health systems varied significantly as did their roles and functions across jurisdictions. Public health systems arrangements generally followed those of health systems, with the addition of partnerships (community and inter-sectoral) and communication playing a larger role in public health. A public health systems framework and conceptualisation of how public health currently fits within health systems are presented.

Conclusions

Public health systems are unique and vital entities within health systems. In addition to examining how public health and public health systems have been defined within the literature, this review suggests that establishing the scope of public health is crucial to understanding its role within the larger health system and adds to the discourse around the relationship between public health, healthcare and population health. More broadly, this study addresses an important gap in understanding public health systems and provides conceptual and practical contributions as well as areas for future research.

Implementation Research: An Efficient and Effective Tool to Accelerate Universal Health Coverage

Success in the implementation of evidence-based interventions (EBIs) in different settings has had variable success. Implementation research offers the approach needed to understand the variability of health outcomes from implementation strategies in different settings and why interventions were successful in some countries and failed in others. When mastered and embedded into a policy and implementation framework, the application of implementation research by countries can provide policy-makers and implementers with the knowledge necessary to work towards universal health coverage (UHC) with the effectiveness, efficiency, sustainability, and fidelity needed to achieve sustainable positive health outcomes for all. To achieve this goal however, work is needed by the communities of research producers and consumers to create more clarity on implementation research methodologies and to build capacity to apply them as a critical tool for countries on their path to achieving UHC.

Significant barriers to diagnosis and management of adrenal insufficiency in Africa

BACKGROUND

The burden and management of primary adrenal insufficiency (PAI) in Africa have not been well documented. We aimed to identify specific disease characteristics, patient demographics, and patterns of clinical management in established PAI in Africa.

METHODS

An online survey of physicians' experience relating to PAI.

RESULTS

There were 1334 responses received, 589 were complete, and 332 respondents reported managing patients with hypoadrenalism. The described responses were related to a calculated pool of 5787 patients with hypoadrenalism (2746 females, 3041 males), of whom 2302 had PAI. The likely causes of PAI in Sub-Saharan Africa (SSA) vs the Middle East and North Africa (MENA) regions included autoimmune disease (20% vs 60.3%; P < 0.001), tuberculosis (34% vs 4.1%; P < 0.001), AIDS (29.8% vs 1%; P < 0.001), malignancy, and genetic conditions. Sixteen percent of AD patients (376/2302) presented in an adrenal crisis. Medical emergency identification was not used by 1233 (83.6%) SSA vs 330 (40.4%) MENA patients (P < 0.001), respectively. Relative non-availability of diagnostic tests across both regions included adrenal antibodies 63% vs 69.6% (P = 0.328), s-cortisol 49.4 % vs 26.7% (P = 0.004), s-ACTH 55.7% vs 53.3% (P = 0.217), and adrenal CT scans 52.4% vs 31.8% (P = 0.017) in the SSA and MENA region, respectively. Across the entire cohort, the overall hydrocortisone use and extrapolated proportion of synacthen use were 59.4% and 50.7%, respectively.

CONCLUSIONS

Through the perception and practice of healthcare professionals, we identified significant challenges in the diagnosis and management of PAI which may herald high mortality. Differences between regions may reflect the allocation of healthcare resources.

Resolution, access, and waiting time for specialties in different models of care

OBJECTIVE

This study aimed to identify the treatment demands coming from primary health care units and, based on that, the demand for referrals to medical specialties in reference services. This study is justified by the scarcity of scientific literature on the subject.

METHODS

This is a cross-sectional study using secondary data on the treatments and referrals made by the primary health care units, throughout 2014, in a municipality of the State of São Paulo, Brazil. The total population treated in 2014 was considered, resulting in 411,177 treatments.

RESULTS

Out of all treatments performed, the percentage of referrals was of 4.42%, showing that 95,58% of the problems did not need to be referred to another service. A number of 8,897 referrals were made, to 6,850 users, who were mostly women (60.74%). The mean of referrals per patient was 1.3 (min. 1 and max. 8), and 1,604 patients (23.5%) were referred at least twice.

CONCLUSIONS

Primary health care services have been responsible for a large number of treatments, whereas the demand for referrals has decreased, suggesting that such services have established themselves as a gateway to the health system and achieved the expected solvability, although the waiting time for some specialties is very long.

Identifying alternative models of healthcare service delivery to inform health system improvement: scoping review of systematic reviews

OBJECTIVE

To describe available evidence from systematic reviews of alternative healthcare delivery arrangements relevant to high-income countries to inform decisions about healthcare system improvement.

DESIGN

Scoping review of systematic reviews.

DATA SOURCES

Systematic reviews of interventions indexed in Pretty Darn Quick-Evidence.

ELIGIBILITY CRITERIA

All English language systematic reviews evaluating the effects of alternative delivery arrangements relevant to high-income countries, published between 1 January 2012 and 20 September 2017. Eligible reviews had to summarise evidence on at least one of the following outcomes: patient outcomes, quality of care, access and/or use of healthcare services, resource use, impacts on equity and/or social outcomes, healthcare provider outcomes or adverse effects.

DATA EXTRACTION AND SYNTHESIS

Journal, publication year, number and design of primary studies, populations/health conditions represented and types of outcomes were extracted.

RESULTS

Of 829 retrieved records, 531 reviews fulfilled our inclusion criteria. Almost all (93%) reviews reported on patient outcomes, while only about one-third included resource use as an outcome of interest. Just over a third (n=189, 36%) of reviews focused on alternative information and communications technology interventions (including 162 reviews on telehealth). About one-quarter (n=122, 23%) of reviews focused on alternative care coordination interventions. 15% (n=80) of reviews examined interventions involving changes to who provides care and how the healthcare workforce is managed. Few reviews investigated the effects of interventions involving changes to how and when care is delivered (n=47, 9%) or interventions addressing a goal-focused question (n=38, 7%).

CONCLUSION

A substantial body of evidence about the effects of a wide range of delivery arrangements is available to inform health system improvements. The lack of economic evaluations in the majority of systematic reviews of delivery arrangements means that the value of many of these models is unknown. This scoping review identifies evidence gaps that would be usefully addressed by future research.

Ethics as a Non-technical Skill for Surgical Education in Sub-Saharan Africa

Background

In recent years, surgical education has increased its focus on the non-technical skills such as communication and interpersonal relationships while continuing to strive for technical excellence of procedures and patient care. An awareness of the ethical aspects of surgical practice that involve non-technical skills and judgment is of vital concern to surgical educators and encompasses disparate issues ranging from adequate supervision of trainees to surgical care access.

Methods

This bibliographical research effort seeks to report on ethical challenges from a sub-Saharan Africa (SSA) perspective as found in the peer-reviewed literature employing African Journals Online, Bioline, and other sources with African information as well as PubMed and PubMed Central. The principles of autonomy, non-maleficence, beneficence, and justice offer a framework for a study of issues including: access to care (socioeconomic issues and distance from health facilities); resource utilization and decision making based on availability and cost of resources, including ICU and terminal extubation; informed consent (both communication about reasonable expectations post-procedure and research participation); research ethics, including local projects and international collaboration; quality and safety including supervision of less experienced professionals; and those religious and cultural issues that may affect any ethical decision making. The religious and cultural environment receives attention because beliefs and traditions affect medical choices ranging from acceptance of procedures, amputations, to end-of-life decisions.

Results and Conclusions

Ethics awareness and ethics education should be a vital component of non-technical skills training in surgical education and medical practice in SSA for trainees. Continuing professional development of faculty should include an awareness of ethical issues.

Effective coverage and budget implications of skill-mix change to improve neonatal nursing care: an explorative simulation study in Kenya

Introduction

Neonatal mortality is an urgent policy priority to improve global population health and reduce health inequality. As health systems in Kenya and elsewhere seek to tackle increased neonatal mortality by improving the quality of care, one option is to train and employ neonatal healthcare assistants (NHCAs) to support professional nurses by taking up low-skill tasks.

Methods

Monte-Carlo simulation was performed to estimate the potential impact of introducing NHCAs in neonatal nursing care in four public hospitals in Nairobi on effectively treated newborns and staff costs over a period of 10 years. The simulation was informed by data from 3 workshops with >10 stakeholders each, hospital records and scientific literature. Two univariate sensitivity analyses were performed to further address uncertainty.

Results

Stakeholders perceived that 49% of a nurse full-time equivalent could be safely delegated to NHCAs in standard care, 31% in intermediate care and 20% in intensive care. A skill-mix with nurses and NHCAs would require ~2.6 billionKenyan Shillings (KES) (US$26 million) to provide quality care to 58% of all newborns in need (ie, current level of coverage in Nairobi) over a period of 10 years. This skill-mix configuration would require ~6 billion KES (US$61 million) to provide quality of care to almost all newborns in need over 10 years.

Conclusion

Changing skill-mix in hospital care by introducing NHCAs may be an affordable way to reduce neonatal mortality in low/middle-income countries. This option should be considered in ongoing policy discussions and supported by further evidence.

Prevalence and factors associated with poor mental health among healthcare professionals in low- and lower-middle-income countries: a systematic review protocol

BACKGROUND

A healthy and productive health workforce is central to a well-functioning health system. However, health workers are at high risk of poor psychological wellbeing due to their particularly strenuous work demands. While mental health of health workers is a well-researched issue in high-income countries, research from low- and lower-middle-income countries (LLMIC) has begun to emerge only recently. The review aims to synthesize this body of research, specifically to assess the prevalence of mental health issues among health workers in LLMIC, to identify factors associated with good or poor mental health, and to highlight gaps in knowledge.

METHODS

We will perform a systematic search of the published English and French language literature (from inception onwards) in MEDLINE, EMBASE, and PsycINFO. Eligible for inclusion are observational studies (e.g., cross-sectional, case-control, or cohort) and control arms of randomized controlled trials reporting investigations on the nature, prevalence, and factors associated with mental health or psychological wellbeing among formally trained health professionals and health associate professionals delivering health services in formal healthcare facilities in LLMIC. The primary outcomes will be burnout, depression, and general psychological wellbeing. Secondary outcomes include other specific mental health diagnoses, as well as general psychological stress, distress and/or trauma if work-related and explicitly framed as a mental health issue. Two authors will independently examine the studies against the eligibility criteria in the stages of title, abstract, and full-text study selection, as well as assess the risk of bias in included studies using standard checklists depending on study design. Disagreements will be resolved in discussion with the third author. Data will be extracted from included studies using a predefined and piloted coding framework. Given the anticipated heterogeneity of studies, we do not expect to be able to conduct meta-analysis and plan to summarize the extracted data in narrative form. The framework method will be used to organize narrative data by subthemes and explore patterns.

DISCUSSION

In assessing the prevalence of mental health issues among healthcare professionals in LLMIC and identifying factors associated with positive or poor mental health, the review aims to synthesize all possible available information for policy makers and health system managers on a potentially highly important but not yet much-discussed issue and to highlight gaps in currently available knowledge.

SYSTEMATIC REVIEW REGISTRATION

International Prospective Register of Systematic Reviews PROSPERO (registration number CRD42019140036).

mHealth intervention "ImTeCHO" to improve delivery of maternal, neonatal, and child care services-A cluster-randomized trial in tribal areas of Gujarat, India

BACKGROUND

The coverage of community-based maternal, neonatal, and child health (MNCH) services remains low, especially in hard-to-reach areas. We evaluated the effectiveness of a mobile-phone-and web-based application, Innovative Mobile-phone Technology for Community Health Operations (ImTeCHO), as a job aid to the government's Accredited Social Health Activists (ASHAs) and Primary Health Center (PHC) staff to improve coverage of MNCH services in rural tribal communities of Gujarat, India.

METHODS AND FINDINGS

This open cluster-randomized trial was conducted in 22 PHCs in six tribal blocks of Bharuch and Narmada districts in India. The ImTeCHO mobile-phone-and web-based application included various technology-based job aids to facilitate scheduling of home visits, screening for complications, counseling during home visits, and supportive supervision by PHC staff. Primary outcome indicators were a composite index calculated based on coverage of important MNCH services and coverage of at least two home visitations by ASHA within the first week of birth. Primary analysis was intention to treat (ITT). Generalized Estimating Equation (GEE) was used to account for clustering. Eleven PHCs each were randomly allocated to the intervention (280 ASHAs, population: 234,134) and control (281 ASHAs, population: 242,809) arms. The intervention was implemented from February, 2016 to January, 2017. At the end of the implementation, 6,493 mothers were surveyed. Most of the surveyed women were tribal (5,571, 85.8%), and reported having a government-issued certificate for living below poverty line (4,916, 75.7%). The coverage of at least two home visits within first week of birth was 32.4% in the intervention clusters compared to 22.9% in the control clusters (adjusted effect size 10.2 [95% CI: 6.4, 14.0], p < 0.001). Mean number of home visits within first week of birth was 1.11 and 0.80 for intervention and control clusters, respectively (adjusted effect size 0.34 [95% CI: 0.23, 0.45], p < 0.001). The composite coverage index was 43.0% in the intervention clusters compared to 38.5% (adjusted effect size 4.9 [95% CI: 0.2, 9.5], p = 0.03) in the control clusters. There were substantial improvements in coverage home visits by ASHAs during antenatal period (adjusted effect size 15.7 [95% CI: 11.0, 20.4], p < 0.001), postnatal period (adjusted effect size 6.4, [95% CI: 3.2, 9.6], p <0.001), early initiation of breastfeeding (adjusted effect size 7.8 [95% CI: 4.2, 11.4], p < 0.001), and exclusive breastfeeding (adjusted effect size 13.4 [95% CI: 8.9, 17.9], p < 0.001). Number of infant and neonatal deaths was similar in the two arms in the ITT analysis. The limitations of the study include potential risk of inaccuracies in reporting events that occurred during pregnancy by the mothers and the duration of intervention being 12 months, which might be considered short.

CONCLUSIONS

In this study, we found that use of ImTeCHO mobile- and web-based application as a job aid by government ASHAs and PHC staff improved coverage and quality of MNCH services in hard-to-reach areas. Supportive supervision, change management, and timely resolution of technology-related issues were critical implementation considerations to ensure adherence to the intervention.

TRIAL REGISTRATION

Study was registered at the Clinical Trial Registry of India (www.ctri.nic.in). Trial number: CTRI/2015/06/005847. The trial was registered (prospective) on 3 June, 2015. First enrollment was done on 26 August, 2015.

Strengthening the Healthcare System in Low- and Middle-income Countries by Integrating Emergency Care Capacities

Primary healthcare (PHC) principles provide a framework for strengthening the healthcare system to tackle increasing and diversifying health needs in low- and middle-income countries (LMICs). Currently, PHC systems in LMICs require expanded care capabilities in order to deal with noncommunicable diseases and injuries, including emergency conditions. In this article, we discuss the possibility of applying PHC principles to emergency care in LMICs and integrating emergency care into PHC; such principles include providing first points of contact with healthcare through nonprofessional providers close to communities in order to improve accessibility, providing high-quality (i.e., comprehensive, coordinated, and continuous) primary care, and addressing primary causes of ill-health through community empowerment. These principles are applicable to emergency care, which has the same attributes: it also requires increasing first points of contact through layperson first aid and the ambulance system, and it also provides comprehensive care for diverse diseases and injuries, with various facilities and personnel involved in its coordinated and continuous delivery; collective community actions also develop and strengthen the emergency care system, particularly through components outside the health sector (e.g., transport, communication, and mutual aid). Integrating emergency care into PHC could enhance the general health system and is more efficient than having separate systems.

White Coats at the Coalface: The Standardizing Work of Professionals at the Frontline

This study advances theory on professionals by introducing a novel ‘coalface perspective’ to study frontline professionals’ standardizing work. Our multimethod quantitative and qualitative approach explores when, why and how medical professionals in German university hospitals actively maintain care pathway enactment – a technique to standardize day-to-day medical work – in their everyday patient treatment. Professionals’ actively standardizing their work is an understudied yet highly relevant phenomenon that the established ‘autonomy perspective’ – which covers how professionals resist standardization – falls short of explaining. Introducing a coalface perspective overcomes this shortcoming by uncovering novel links between professionals’ day-to-day problem-driven motivations for standardizing work, the characteristics of everyday situations of frontline professional work and practices of standardizing work at the frontline. This study has implications for research on frontline professionals and coalface-perspective research in general.

Communication around HPV vaccination for adolescents in low- and middle-income countries: a systematic scoping overview of systematic reviews

BACKGROUND

Human papillomavirus (HPV) infection causes cervical cancer. More than 80% of those diagnosed with cervical cancer live in low- and middle-income countries (LMICs). The World Health Organization recommends vaccination as a public health measure against cervical cancer. Communication interventions are able to change how people think about vaccination and are thus instrumental in addressing vaccine hesitancy. Our aim was to provide a broad scoping overview of the available evidence on communication with adolescents, parents, and other stakeholders around HPV vaccination for adolescents, with a specific focus on LMICs.

METHODS

We conducted a systematic scoping overview of systematic reviews addressing a range of questions regarding communication around HPV vaccination. We considered reviews published between 2007 and 2018 focusing on communication around HPV vaccination and that searched for qualitative or quantitative studies for inclusion. We searched the Epistemonikos database which includes reviews from multiple electronic databases. Two overview authors screened titles and abstracts and examined potentially eligible reviews in full text. Data extraction was performed by one overview author and verified by a second. We assessed the reliability of the included reviews using an adapted version of AMSTAR 2.

RESULTS

We included twelve reviews in our overview. Four reviews assessed the effectiveness of communication interventions. These interventions intended to inform or educate about HPV and HPV vaccination, such as videos and fact sheets, or to remind or recall, such as text message reminders. Eight reviews assessed factors associated with HPV vaccination uptake, including communication-related factors such as whether the vaccine was recommended by a physician and people's knowledge regarding the vaccine. Nine reviews searched for studies from LMICs, but most found only a small number of studies from these countries.

CONCLUSIONS

The small number of studies identified from LMICs is of concern as these countries face the largest burden of disease related to HPV. This scoping overview also found and excluded a number of reviews because of important methodological limitations, highlighting the need for future reviews to use appropriate methods. The overview indicates areas in which further primary studies are needed on HPV vaccination communication in LMICs.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework https://osf.io/agzb4/.

A systematic review of the effectiveness of strategies to improve health care provider performance in low- and middle-income countries: Methods and descriptive results

BACKGROUND

Health care provider (HCP) performance in low- and middle-income countries (LMICs) is often inadequate. The Health Care Provider Performance Review (HCPPR) is a comprehensive systematic review of the effectiveness and cost of strategies to improve HCP performance in LMICs. We present the HCPPR's methods, describe methodological and contextual attributes of included studies, and examine time trends of study attributes.

METHODS

The HCPPR includes studies from LMICs that quantitatively evaluated any strategy to improve HCP performance for any health condition, with no language restrictions. Eligible study designs were controlled trials and interrupted time series. In 2006, we searched 15 databases for published studies; in 2008 and 2010, we completed searches of 30 document inventories for unpublished studies. Data from eligible reports were double-abstracted and entered into a database, which is publicly available. The primary outcome measure was the strategy's effect size. We assessed time trends with logistic, Poisson, and negative binomial regression modeling. We were unable to register with PROSPERO (International Prospective Register of Systematic Reviews) because the protocol was developed prior to the PROSPERO launch.

RESULTS

We screened 105,299 citations and included 824 reports from 499 studies of 161 intervention strategies. Most strategies had multiple components and were tested by only one study each. Studies were from 79 countries and had diverse methodologies, geographic settings, HCP types, work environments, and health conditions. Training, supervision, and patient and community supports were the most commonly evaluated strategy components. Only 33.6% of studies had a low or moderate risk of bias. From 1958-2003, the number of studies per year and study quality increased significantly over time, as did the proportion of studies from low-income countries. Only 36.3% of studies reported information on strategy cost or cost-effectiveness.

CONCLUSIONS

Studies have reported on the efficacy of many strategies to improve HCP performance in LMICs. However, most studies have important methodological limitations. The HCPPR is a publicly accessible resource for decision-makers, researchers, and others interested in improving HCP performance.

Combining volunteers and primary care teamwork to support health goals and needs of older adults: a pragmatic randomized controlled trial

BACKGROUND

The Health TAPESTRY (Health Teams Advancing Patient Experience: STRengthening QualitY) intervention was designed to improve primary care teamwork and promote optimal aging. We evaluated the effectiveness of Health TAPESTRY in attaining goals of older adults (e.g., physical activity, productivity, social connection, medical status) and other outcomes.

METHODS

We conducted a pragmatic randomized controlled trial between January and October 2015 in a primary care practice in Hamilton, Ontario. Older adults were randomized (1:1) to Health TAPESTRY (n = 158) or control (n = 154). Trained community volunteers gathered information on people's goals, needs and risks in their homes, using electronic forms. Interprofessional primary care teams reviewed summaries and addressed issues. Participants reported goal attainment (primary outcome), self-efficacy, quality of life, optimal aging, social support, empowerment, physical activity, falls, and access to and comprehensiveness of the health system. We determined use of health care resources through chart audit.

RESULTS

There were no differences between groups in goal attainment or many other patient-reported outcome and experience assessments at 6 months. More primary care visits took place in the intervention versus control group over 6 months (mean ± standard deviation [SD] 4.93 ± 3.86 v. 3.50 ± 3.53; difference of 1.52 [95% confidence interval (CI) 0.84 to 2.19]). The odds of having 1 or more hospital admission were lower for the intervention group (odds ratio [OR] 0.44 [95% CI 0.20 to 0.95]).

INTERPRETATION

Health TAPESTRY did not improve the primary outcome of goal attainment but showed signals of shifting care from reactive to active preventive care. Further evaluation will help in understanding effective components, costs and consequences of the intervention. Trial registration: ClinicalTrials.gov, no. NCT02283723.

Alternative service models for delivery of healthcare services in high-income countries: a scoping review of systematic reviews

INTRODUCTION

Costs associated with the delivery of healthcare services are growing at an unsustainable rate. There is a need for health systems and healthcare providers to consider the economic impacts of the service models they deliver and to determine if alternative models may lead to improved efficiencies without compromising quality of care. The aim of this protocol is to describe a scoping review of the extent, range and nature of available synthesised research on alternative delivery arrangements for health systems relevant to high-income countries published in the last 5 years.

DESIGN

We will perform a scoping review of systematic reviews of trials and economic studies of alternative delivery arrangements for health systems relevant to high-income countries published on 'Pretty Darn Quick' (PDQ)-Evidence between 1 January 2012 and 20 September 2017. All English language systematic reviews will be included. The Cochrane Effective Practice and Organisation of Care taxonomy of health system interventions will be used to categorise delivery arrangements according to: how and when care is delivered, where care is provided and changes to the healthcare environment, who provides care and how the healthcare workforce is managed, co-ordination of care and management of care processes and information and communication technology systems. This work is part of a 5-year Partnership Centre for Health System Sustainability aiming to investigate and create interventions to improve health-system-performance sustainability.

ETHICS AND DISSEMINATION

No primary data will be collected, so ethical approval is not required. The study findings will be published and presented at relevant conferences.

Can we achieve universal health coverage without a focus on disability? Results from a national case-control study in Guatemala

OBJECTIVE

To compare access to healthcare services for people with disabilities to those without disabilities, within a national case-control study in Guatemala.

METHODS

We undertook a population-based case-control study, nested within a national survey in Guatemala. Cases with disabilities were people with self-reported difficulties in functioning. One control without disabilities was selected per case, matched by age, gender and cluster. Information was collected on: health status, access to health services and rehabilitation, and socioeconomic status.

RESULTS

The study included 707 people with disabilities, and 465 controls. People with disabilities were more likely to report a serious health problem (aOR 2.8, 2.2-3.7) or doctor-diagnosis of one of 17 general health conditions (aOR 2.9, 2.2-3.8) as compared to controls without disabilities. People with disabilities were twice as likely as controls to have received treatment for a diagnosed condition (aOR 2.2, 1.7-2.8). Coverage of treatment for impairment-related health conditions was low, as was awareness and access to rehabilitation services. People with disabilities were more likely than controls to report being disrespected (aOR 1.9, 1.0-3.7) or finding it difficult to understand information given (aOR 1.6, 1.1-1.4).

CONCLUSION

Efforts are needed to raise awareness about rehabilitation services and improve quality of health services for people with disabilities in Guatemala, to ensure that their rights are fulfilled and to assist in the achievement of Universal Health Coverage. Better tools are needed to measure healthcare access, including consideration of geographic access, quality and affordability, to allow the generation of comparable data on access to healthcare among people with disabilities.

Interventions during pregnancy to prevent preterm birth: an overview of Cochrane systematic reviews

BACKGROUND

Preterm birth (PTB) is a major factor contributing to global rates of neonatal death and to longer-term health problems for surviving infants. Both the World Health Organization and the United Nations consider prevention of PTB as central to improving health care for pregnant women and newborn babies. Current preventative clinical strategies show varied efficacy in different populations of pregnant women, frustrating women and health providers alike, while researchers call for better understanding of the underlying mechanisms that lead to PTB.

OBJECTIVES

We aimed to summarise all evidence for interventions relevant to the prevention of PTB as reported in Cochrane systematic reviews (SRs). We intended to highlight promising interventions and to identify SRs in need of an update.

METHODS

We searched the Cochrane Database of Systematic Reviews (2 November 2017) with key words to capture any Cochrane SR that prespecified or reported a PTB outcome. Inclusion criteria focused on pregnant women without signs of preterm labour or ruptured amniotic membranes. We included reviews of interventions for pregnant women irrespective of their risk status. We followed standard Cochrane methods.We applied GRADE criteria to evaluate the quality of SR evidence. We assigned graphic icons to classify the effectiveness of interventions as: clear evidence of benefit; clear evidence of harm; clear evidence of no effect or equivalence; possible benefit; possible harm; or unknown benefit or harm. We defined clear evidence of benefit and clear evidence of harm to be GRADE moderate- or high-quality evidence with a confidence interval (CI) that does not cross the line of no effect. Clear evidence of no effect or equivalence is GRADE moderate- or high-quality evidence with a narrow CI crossing the line of no effect. Possible benefit and possible harm refer to GRADE low-quality evidence with a clear effect (CI does not cross the line of no effect) or GRADE moderate- or high-quality evidence with a wide CI. Unknown harm or benefit refers to GRADE low- or very low-quality evidence with a wide CI.

MAIN RESULTS

We included 83 SRs; 70 had outcome data. Below we highlight key results from a subset of 36 SRs of interventions intended to prevent PTB.

OUTCOME

preterm birthClear evidence of benefitFour SRs reported clear evidence of benefit to prevent specific populations of pregnant women from giving birth early, including midwife-led continuity models of care versus other models of care for all women; screening for lower genital tract infections for pregnant women less than 37 weeks' gestation and without signs of labour, bleeding or infection; and zinc supplementation for pregnant women without systemic illness. Cervical cerclage showed clear benefit for women with singleton pregnancy and high risk of PTB only.Clear evidence of harmNo included SR reported clear evidence of harm.No effect or equivalenceFor pregnant women at high risk of PTB, bedrest for women with singleton pregnancy and antibiotic prophylaxis during the second and third trimester were of no effect or equivalent to a comparator.Possible benefitFour SRs found possible benefit in: group antenatal care for all pregnant women; antibiotics for pregnant women with asymptomatic bacteriuria; pharmacological interventions for smoking cessation for pregnant women who smoke; and vitamin D supplements alone for women without pre-existing conditions such as diabetes.Possible harmOne SR reported possible harm (increased risk of PTB) with intramuscular progesterone, but this finding is only relevant to women with multiple pregnancy and high risk of PTB. Another review found possible harm with vitamin D, calcium and other minerals for pregnant women without pre-existing conditions.

OUTCOME

perinatal deathClear evidence of benefitTwo SRs reported clear evidence of benefit to reduce pregnant women's risk of perinatal death: midwife-led continuity models of care for all pregnant women; and fetal and umbilical Doppler for high-risk pregnant women.Clear evidence of harmNo included SR reported clear evidence of harm.No effect or equivalenceFor pregnant women at high risk of PTB, antibiotic prophylaxis during the second and third trimester was of no effect or equivalent to a comparator.Possible benefitOne SR reported possible benefit with cervical cerclage for women with singleton pregnancy and high risk of PTB.Possible harmOne SR reported possible harm associated with a reduced schedule of antenatal visits for pregnant women at low risk of pregnancy complications; importantly, these women already received antenatal care in settings with limited resources.

OUTCOMES

preterm birth and perinatal deathUnknown benefit or harmFor pregnant women at high risk of PTB for any reason including multiple pregnancy, home uterine monitoring was of unknown benefit or harm. For pregnant women at high risk due to multiple pregnancy: bedrest, prophylactic oral betamimetics, vaginal progesterone and cervical cerclage were all of unknown benefit or harm.

AUTHORS' CONCLUSIONS

Implications for practiceThe overview serves as a map and guide to all current evidence relevant to PTB prevention published in the Cochrane Library. Of 70 SRs with outcome data, we identified 36 reviews of interventions with the aim of preventing PTB. Just four of these SRs had evidence of clear benefit to women, with an additional four SRs reporting possible benefit. No SR reported clear harm, which is an important finding for women and health providers alike.The overview summarises no evidence for the clinically important interventions of cervical pessary, cervical length assessment and vaginal progesterone because these Cochrane Reviews were not current. These are active areas for PTB research.The graphic icons we assigned to SR effect estimates do not constitute clinical guidance or an endorsement of specific interventions for pregnant women. It remains critical for pregnant women and their healthcare providers to carefully consider whether specific strategies to prevent PTB will be of benefit for individual women, or for specific populations of women.Implications for researchFormal consensus work is needed to establish standard language for overviews of reviews and to define the limits of their interpretation.Clinicians, researchers and funders must address the lack of evidence for interventions relevant to women at high risk of PTB due to multiple pregnancy.

Evidence gap map of performance measurement and management in primary care delivery systems in low- and middle-income countries - Study protocol

Background . For the last two decades there has been growing interest in governmental and global health stakeholders about the role that performance measurement and management systems can play for the production of high-quality and safely delivered primary care services. Despite recognition and interest, the gaps in evidence in this field of research and practice in low- and middle-income countries remain poorly characterized. This study will develop an evidence gap map in the area of performance management in primary care delivery systems in low- and middle-income countries. Methods. The evidence gap map will follow the methodology developed by 3Ie, the International Initiative for Impact Evaluation, to systematically map evidence and research gaps. The process starts with the development of the scope by creating an evidence-informed framework that helps identify the interventions and outcomes of relevance as well as help define inclusion and exclusion criteria. A search strategy is then developed to guide the systematic search of the literature, covering the following databases: Medline (Ovid), Embase (Ovid), CAB Global Health (Ovid), CINAHL (Ebsco), Cochrane Library, Scopus (Elsevier), and Econlit (Ovid). Sources of grey literature are also searched. Studies that meet the inclusion criteria are systematically coded, extracting data on intervention, outcome, measures, context, geography, equity, and study design. Systematic reviews are also critically appraised using an existing standard checklist. Impact evaluations are not appraised but will be coded according to study design. The process of map-building ends with the creation of an evidence gap map graphic that displays the available evidence according to the intervention and outcome framework of interest. Discussion . Implications arising from the evidence map will be discussed in a separate paper that will summarize findings and make recommendations for the development of a prioritized research agenda.

Effectiveness of strategies to improve health-care provider practices in low-income and middle-income countries: a systematic review

Background

Inadequate health-care provider performance is a major challenge to the delivery of high-quality health care in low-income and middle-income countries (LMICs). The Health Care Provider Performance Review (HCPPR) is a comprehensive systematic review of strategies to improve health-care provider performance in LMICs.

Methods

For this systematic review we searched 52 electronic databases for published studies and 58 document inventories for unpublished studies from the 1960s to 2016. Eligible study designs were controlled trials and interrupted time series. We only included strategy-versus-control group comparisons. We present results of improving health-care provider practice outcomes expressed as percentages (eg, percentage of patients treated correctly) or as continuous measures (eg, number of medicines prescribed per patient). Effect sizes were calculated as absolute percentage-point changes. The summary measure for each comparison was the median effect size (MES) for all primary outcomes. Strategy effectiveness was described with weighted medians of MES. This study is registered with PROSPERO, number CRD42016046154.

Findings

We screened 216 477 citations and selected 670 reports from 337 studies of 118 strategies. Most strategies had multiple intervention components. For professional health-care providers (generally, facility-based health workers), the effects were near zero for only implementing a technology-based strategy (median MES 1·0 percentage points, IQR −2·8 to 9·9) or only providing printed information for health-care providers (1·4 percentage points, −4·8 to 6·2). For percentage outcomes, training or supervision alone typically had moderate effects (10·3–15·9 percentage points), whereas combining training and supervision had somewhat larger effects than use of either strategy alone (18·0–18·8 percentage points). Group problem solving alone showed large improvements in percentage outcomes (28·0–37·5 percentage points), but, when the strategy definition was broadened to include group problem solving alone or other strategy components, moderate effects were more typical (12·1 percentage points). Several multifaceted strategies had large effects, but multifaceted strategies were not always more effective than simpler ones. For lay health-care providers (generally, community health workers), the effect of training alone was small (2·4 percentage points). Strategies with larger effect sizes included community support plus health-care provider training (8·2–125·0 percentage points). Contextual and methodological heterogeneity made comparisons difficult, and most strategies had low quality evidence.

Interpretation

The impact of strategies to improve health-care provider practices varied substantially, although some approaches were more consistently effective than others. The breadth of the HCPPR makes its results valuable to decision makers for informing the selection of strategies to improve health-care provider practices in LMICs. These results also emphasise the need for researchers to use better methods to study the effectiveness of interventions.

Funding

Bill & Melinda Gates Foundation, CDC Foundation.

The GRADE Evidence to Decision (EtD) framework for health system and public health decisions

OBJECTIVE

To describe a framework for people making and using evidence-informed health system and public health recommendations and decisions.

BACKGROUND

We developed the GRADE Evidence to Decision (EtD) framework for health system and public health decisions as part of the DECIDE project, in which we simultaneously developed frameworks for these and other types of healthcare decisions, including clinical recommendations, coverage decisions and decisions about diagnostic tests.

DEVELOPING THE FRAMEWORK

Building on GRADE EtD tables, we used an iterative approach, including brainstorming, consultation of the literature and with stakeholders, and an international survey of policy-makers. We applied the framework to diverse examples, conducted workshops and user testing with health system and public health guideline developers and policy-makers, and observed and tested its use in real-life guideline panels.

FINDINGS

All the GRADE EtD frameworks share the same basic structure, including sections for formulating the question, making an assessment and drawing conclusions. Criteria listed in the assessment section of the health system and public health framework cover the important factors for making these types of decisions; in addition to the effects and economic impact of an option, the priority of the problem, the impact of the option on equity, and its acceptability and feasibility are important considerations that can inform both whether and how to implement an option. Because health system and public health interventions are often complex, detailed implementation considerations should be made when making a decision. The certainty of the evidence is often low or very low, but decision-makers must still act. Monitoring and evaluation are therefore often important considerations for these types of decisions. We illustrate the different components of the EtD framework for health system and public health decisions by presenting their application in a framework adapted from a real-life guideline.

DISCUSSION

This framework provides a structured and transparent approach to support policy-making informed by the best available research evidence, while making the basis for decisions accessible to those whom they will affect. The health system and public health EtD framework can also be used to facilitate dissemination of recommendations and enable decision-makers to adopt, and adapt, recommendations or decisions.

Evidence gap map of performance measurement and management in primary care delivery systems in low- and middle-income countries - Study protocol

Background. For the last two decades there has been growing interest in governmental and global health stakeholders about the role that performance measurement and management systems can play for the production of high-quality and safely delivered primary care services. Despite recognition and interest, the gaps in evidence in this field of research and practice in low- and middle-income countries remain poorly characterized. This study will develop an evidence gap map in the area of performance management in primary care delivery systems in low- and middle-income countries. Methods. The evidence gap map will follow the methodology developed by 3Ie, the International Initiative for Impact Evaluation, to systematically map evidence and research gaps. The process starts with the development of the scope by creating an evidence-informed framework that helps identify the interventions and outcomes of relevance as well as help define inclusion and exclusion criteria. A search strategy is then developed to guide the systematic search of the literature, covering the following databases: Medline (Ovid), Embase (Ovid), CAB Global Health (Ovid), CINAHL (Ebsco), Cochrane Library, Scopus (Elsevier), and Econlit (Ovid). Sources of grey literature are also searched. Studies that meet the inclusion criteria are systematically coded, extracting data on intervention, outcome, measures, context, geography, equity, and study design. Systematic reviews are also critically appraised using an existing standard checklist. Impact evaluations are not appraised but will be coded according to study design. The process of map-building ends with the creation of an evidence gap map graphic that displays the available evidence according to the intervention and outcome framework of interest. Discussion. Applications arising from the evidence map will be discussed in a separate paper that will summarize findings and make recommendations for the development of a prioritized research agenda.

Delivery arrangements for health systems in low-income countries: an overview of systematic reviews

BACKGROUND

Delivery arrangements include changes in who receives care and when, who provides care, the working conditions of those who provide care, coordination of care amongst different providers, where care is provided, the use of information and communication technology to deliver care, and quality and safety systems. How services are delivered can have impacts on the effectiveness, efficiency and equity of health systems. This broad overview of the findings of systematic reviews can help policymakers and other stakeholders identify strategies for addressing problems and improve the delivery of services.

OBJECTIVES

To provide an overview of the available evidence from up-to-date systematic reviews about the effects of delivery arrangements for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on delivery arrangements and informing refinements of the framework for delivery arrangements outlined in the review.

METHODS

We searched Health Systems Evidence in November 2010 and PDQ-Evidence up to 17 December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of delivery arrangements on patient outcomes (health and health behaviours), the quality or utilisation of healthcare services, resource use, healthcare provider outcomes (such as sick leave), or social outcomes (such as poverty or employment) and that were published after April 2005. We excluded reviews with limitations important enough to compromise the reliability of the findings. Two overview authors independently screened reviews, extracted data, and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence), and assessments of the relevance of findings to low-income countries.

MAIN RESULTS

We identified 7272 systematic reviews and included 51 of them in this overview. We judged 6 of the 51 reviews to have important methodological limitations and the other 45 to have only minor limitations. We grouped delivery arrangements into eight categories. Some reviews provided more than one comparison and were in more than one category. Across these categories, the following intervention were effective; that is, they have desirable effects on at least one outcome with moderate- or high-certainty evidence and no moderate- or high-certainty evidence of undesirable effects. Who receives care and when: queuing strategies and antenatal care to groups of mothers. Who provides care: lay health workers for caring for people with hypertension, lay health workers to deliver care for mothers and children or infectious diseases, lay health workers to deliver community-based neonatal care packages, midlevel health professionals for abortion care, social support to pregnant women at risk, midwife-led care for childbearing women, non-specialist providers in mental health and neurology, and physician-nurse substitution. Coordination of care: hospital clinical pathways, case management for people living with HIV and AIDS, interactive communication between primary care doctors and specialists, hospital discharge planning, adding a service to an existing service and integrating delivery models, referral from primary to secondary care, physician-led versus nurse-led triage in emergency departments, and team midwifery. Where care is provided: high-volume institutions, home-based care (with or without multidisciplinary team) for people living with HIV and AIDS, home-based management of malaria, home care for children with acute physical conditions, community-based interventions for childhood diarrhoea and pneumonia, out-of-facility HIV and reproductive health services for youth, and decentralised HIV care. Information and communication technology: mobile phone messaging for patients with long-term illnesses, mobile phone messaging reminders for attendance at healthcare appointments, mobile phone messaging to promote adherence to antiretroviral therapy, women carrying their own case notes in pregnancy, interventions to improve childhood vaccination. Quality and safety systems: decision support with clinical information systems for people living with HIV/AIDS. Complex interventions (cutting across delivery categories and other health system arrangements): emergency obstetric referral interventions.

AUTHORS' CONCLUSIONS

A wide range of strategies have been evaluated for improving delivery arrangements in low-income countries, using sound systematic review methods in both Cochrane and non-Cochrane reviews. These reviews have assessed a range of outcomes. Most of the available evidence focuses on who provides care, where care is provided and coordination of care. For all the main categories of delivery arrangements, we identified gaps in primary research related to uncertainty about the applicability of the evidence to low-income countries, low- or very low-certainty evidence or a lack of studies.

Implementation strategies for health systems in low-income countries: an overview of systematic reviews

BACKGROUND

A key function of health systems is implementing interventions to improve health, but coverage of essential health interventions remains low in low-income countries. Implementing interventions can be challenging, particularly if it entails complex changes in clinical routines; in collaborative patterns among different healthcare providers and disciplines; in the behaviour of providers, patients or other stakeholders; or in the organisation of care. Decision-makers may use a range of strategies to implement health interventions, and these choices should be based on evidence of the strategies' effectiveness.

OBJECTIVES

To provide an overview of the available evidence from up-to-date systematic reviews about the effects of implementation strategies for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on alternative implementation strategies and informing refinements of the framework for implementation strategies presented in the overview.

METHODS

We searched Health Systems Evidence in November 2010 and PDQ-Evidence up to December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of implementation strategies on professional practice and patient outcomes and that were published after April 2005. We excluded reviews with limitations important enough to compromise the reliability of the review findings. Two overview authors independently screened reviews, extracted data and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence) and assessments of the relevance of findings to low-income countries.

MAIN RESULTS

We identified 7272 systematic reviews and included 39 of them in this overview. An additional four reviews provided supplementary information. Of the 39 reviews, 32 had only minor limitations and 7 had important methodological limitations. Most studies in the reviews were from high-income countries. There were no studies from low-income countries in eight reviews.Implementation strategies addressed in the reviews were grouped into four categories - strategies targeting:1. healthcare organisations (e.g. strategies to change organisational culture; 1 review);2. healthcare workers by type of intervention (e.g. printed educational materials; 14 reviews);3. healthcare workers to address a specific problem (e.g. unnecessary antibiotic prescription; 9 reviews);4. healthcare recipients (e.g. medication adherence; 15 reviews).Overall, we found the following interventions to have desirable effects on at least one outcome with moderate- or high-certainty evidence and no moderate- or high-certainty evidence of undesirable effects.1.Strategies targeted at healthcare workers: educational meetings, nutrition training of health workers, educational outreach, practice facilitation, local opinion leaders, audit and feedback, and tailored interventions.2.Strategies targeted at healthcare workers for specific types of problems: training healthcare workers to be more patient-centred in clinical consultations, use of birth kits, strategies such as clinician education and patient education to reduce antibiotic prescribing in ambulatory care settings, and in-service neonatal emergency care training.3. Strategies targeted at healthcare recipients: mass media interventions to increase uptake of HIV testing; intensive self-management and adherence, intensive disease management programmes to improve health literacy; behavioural interventions and mobile phone text messages for adherence to antiretroviral therapy; a one time incentive to start or continue tuberculosis prophylaxis; default reminders for patients being treated for active tuberculosis; use of sectioned polythene bags for adherence to malaria medication; community-based health education, and reminders and recall strategies to increase vaccination uptake; interventions to increase uptake of cervical screening (invitations, education, counselling, access to health promotion nurse and intensive recruitment); health insurance information and application support.

AUTHORS' CONCLUSIONS

Reliable systematic reviews have evaluated a wide range of strategies for implementing evidence-based interventions in low-income countries. Most of the available evidence is focused on strategies targeted at healthcare workers and healthcare recipients and relates to process-based outcomes. Evidence of the effects of strategies targeting healthcare organisations is scarce.

Governance arrangements for health systems in low-income countries: an overview of systematic reviews

BACKGROUND

Governance arrangements include changes in rules or processes that determine authority and accountability for health policies, organisations, commercial products and health professionals, as well as the involvement of stakeholders in decision-making. Changes in governance arrangements can affect health and related goals in numerous ways, generally through changes in authority, accountability, openness, participation and coherence. A broad overview of the findings of systematic reviews can help policymakers, their technical support staff and other stakeholders to identify strategies for addressing problems and improving the governance of their health systems.

OBJECTIVES

To provide an overview of the available evidence from up-to-date systematic reviews about the effects of governance arrangements for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on governance arrangements and informing refinements of the framework for governance arrangements outlined in the overview.

METHODS

We searched Health Systems Evidence in November 2010 and PDQ Evidence up to 17 December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of governance arrangements on patient outcomes (health and health behaviours), the quality or utilisation of healthcare services, resource use (health expenditures, healthcare provider costs, out-of-pocket payments, cost-effectiveness), healthcare provider outcomes (such as sick leave), or social outcomes (such as poverty, employment) and that were published after April 2005. We excluded reviews with limitations that were important enough to compromise the reliability of the findings of the review. Two overview authors independently screened reviews, extracted data and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence) and assessments of the relevance of findings to low-income countries.

MAIN RESULTS

We identified 7272 systematic reviews and included 21 of them in this overview (19 primary reviews and 2 supplementary reviews). We focus here on the results of the 19 primary reviews, one of which had important methodological limitations. The other 18 were reliable (with only minor limitations).We grouped the governance arrangements addressed in the reviews into five categories: authority and accountability for health policies (three reviews); authority and accountability for organisations (two reviews); authority and accountability for commercial products (three reviews); authority and accountability for health professionals (seven reviews); and stakeholder involvement (four reviews).Overall, we found desirable effects for the following interventions on at least one outcome, with moderate- or high-certainty evidence and no moderate- or high-certainty evidence of undesirable effects. Decision-making about what is covered by health insurance- Placing restrictions on the medicines reimbursed by health insurance systems probably decreases the use of and spending on these medicines (moderate-certainty evidence). Stakeholder participation in policy and organisational decisions- Participatory learning and action groups for women probably improve newborn survival (moderate-certainty evidence).- Consumer involvement in preparing patient information probably improves the quality of the information and patient knowledge (moderate-certainty evidence). Disclosing performance information to patients and the public- Disclosing performance data on hospital quality to the public probably encourages hospitals to implement quality improvement activities (moderate-certainty evidence).- Disclosing performance data on individual healthcare providers to the public probably leads people to select providers that have better quality ratings (moderate-certainty evidence).

AUTHORS' CONCLUSIONS

Investigators have evaluated a wide range of governance arrangements that are relevant for low-income countries using sound systematic review methods. These strategies have been targeted at different levels in health systems, and studies have assessed a range of outcomes. Moderate-certainty evidence shows desirable effects (with no undesirable effects) for some interventions. However, there are important gaps in the availability of systematic reviews and primary studies for the all of the main categories of governance arrangements.