How to bridge the gap in human resources for health

Effects of work-family conflict on turnover intention among primary medical staff in Huaihai Economic Zone: a mediation model through burnout

Background

Countries worldwide face the challenge of how medical personnel manage conflicts between work and family. Especially after the challenge of the COVID-19 epidemic, it is necessary to explore the possible mechanisms of work-family conflict, burnout, and turnover intention among primary medical staff.

Objectives

This study aims to observe the turnover intention of Chinese primary medical staff and explore the relationship between work-family conflict, burnout, and turnover intention.

Methods

A cross-sectional study included a turnover intention questionnaire, the Maslach Burnout Inventory-General Survey (MBI-GS), and the Work-Family Conflict Scale (WFCS) to understand turnover intention, burnout, and work-family conflict among primary medical staff in four cities (Xuzhou, Linyi, Huaibei, and Shangqiu cities) within the Huaihai Economic Zone. Spearman correlation analysis and hierarchical multiple regression analysis were used to examine the related factors of turnover intention. Structural equation modeling (SEM) was used to study the mediating role of burnout between work-family conflict and turnover intention.

Results

In this study, there is a positive correlation between work-family conflict and turnover intention (P < 0.01). Demographic characteristics, work-family conflict, and burnout explained 2.3%, 20.3%, and 8.8% of the incremental variances, respectively. Burnout mediated the association between work-family conflict and turnover intention.

Conclusions

Burnout can be regarded as a mediator between two different variables: work-family conflict and turnover intention. Improving work-family conflict and alleviating burnout may play a key role in reducing the willingness of primary medical staff to resign. Corresponding measures can be taken to balance the conflict between work and family, alleviate burnout, reduce turnover rates, and build a primary medical staff team with higher medical service quality and stability.

Exploring doctors' trade-offs between management, research and clinical training in the medical curriculum: a protocol for a discrete choice experiment in Southern Africa

INTRODUCTION

Medical curricula should prepare doctors for roles that extend beyond that of a clinician. But the formal inclusion of both management and research training still appear to be neglected. It is important to understand what the profession would be willing to give up in terms of clinical training time for management and research content teaching prior to making any changes in a medical curriculum.

METHODS AND ANALYSIS

A discrete choice experiment will elicit the preferences and trade-offs that medical doctors in Southern Africa are prepared to make about the management, research and clinical training. Attention will also be given to the teaching method and placement of the content. DCE data will be collected using an online survey with an estimated sample size of 368 medical doctors. Data regarding participants' preference for a traditional or revised curriculum will be assessed using the Resistance to Change-Beliefs (RC-B) scale and demographic information will also be collected to assess preference heterogeneity.Analysis of the DCE data will be based on the Random Utility Maximisation framework using variants of the multinomial logit model. Data quality will be assessed. Value will be estimated in terms of clinical time, that is, how much clinical training time medical doctors are willing to give up to have research and management training within a curriculum that has a maximum of 40 hours per week. Observed preference heterogeneity will be assessed using the RC-B scale data and characteristics of respondents. Latent class models will be used to test for unobserved heterogeneity.

ETHICS AND DISSEMINATION

The research ethics and institutional committees of the sites have approved the study. The survey includes an informed consent section. Study findings will be reported to the medical schools and papers will be submitted to peer-reviewed, accredited journals and higher education and health economic conferences.

Obstetric anaesthesia manpower and service provision issues (introduction and European perspective)

Global health is an important and far-reaching concept in which health and access to surgical and anaesthetic care is crucial. Universal access to anaesthesia is a challenge in many countries. Manpower shortages are an important cause of difficulties and each European country has found different ways of facing a lack of healthcare professionals. In obstetric anaesthesia, the availability of competent anaesthesiologists has been related to the morbidity and mortality outcomes of patients. In this narrative review, authors from different European countries explain how manpower is managed in obstetric anaesthesia in delivery suites and obstetric operating rooms in different settings. To address manpower difficulties and issues, the goals are to achieve a minimum standard of care and at the same time, to promote clinical excellence through training, delegation to younger or less experienced colleagues, direct or at-a-distance supervision, or other means. The experience of sharing knowledge about the way in which manpower and service provision are organised in other healthcare settings is a significant opportunity to develop strategies for advancing tomorrow's obstetric anaesthesia in the world. While taking into account the level of socio-economic development in different countries, the aim is to standardise practice and workload organisation. Co-operative international projects in training and education in obstetric anaesthesia are ways in which better obstetric patient care can be achieved in the future.

Distribution of nursing workforce in the world using Gini coefficient

INTRODUCTION

Unequal Access to human resources for health, reduces access to healthcare services, worsens the quality of services and reduces health outcomes. This study aims to investigate the distribution of the nursing workforce around the world.

METHODS

This is a descriptive-analytical study, which was conducted in 2021. The number of nurses and world populations was gathered from World Health Organization (WHO) and The United Nations (UN) databases. The UN has divided world countries based on the Human Development Index (HDI) into four categories of very high, high, medium and low HDI. To investigate the distribution of the nurses around the world, we used the nurse population ratio (per 10,000 population), Gini coefficient, Lorenz curve and Pareto curve.

FINDINGS

On average, there were 38.6 nurses for every 10,000 people in the world. Nations with the very high HDI, had the highest nurse/population ratio (95/10,000), while the low HDI nations had the lowest nurse/population ratio (7/10,000). Most nurses around the world were females (76.91%) who were in the age group of 35-44 (29.1%). The Gini coefficient of nations in the each four HDI categories varied from 0.217 to 0.283. The Gini coefficient of the nations between the four HDI categories was 0.467, and the Gini coefficient of the whole world was 0.667.

CONCLUSION

There were inequalities between countries all over the world. Policymakers should focus on the equitable distribution of the nursing workforce across all local, national and regional levels.

Scrutinizing human resources for health availability and distribution in Mozambique between 2016 and 2020: a subnational descriptive longitudinal study

INTRODUCTION

Overall, resilient health systems build upon sufficient, qualified, well-distributed, and motivated health workers; however, this precious resource is limited in numbers to meet people's demands, particularly in LMICs. Understanding the subnational distribution of health workers from different lens is critical to ensure quality healthcare and improving health outcomes.

METHODS

Using data from Health Personnel Information System, facility-level Service Availability and Readiness Assessment, and other sources, we performed a district-level longitudinal analysis to assess health workforce density and the ratio of male to female health workers between January 2016 and June 2020 across all districts in Mozambique.

RESULTS

22 011 health workers were sampled, of whom 10 405 (47.3%) were male. The average age was 35 years (SD: 9.4). Physicians (1025, 4.7%), maternal and child health nurses (4808, 21.8%), and nurses (6402, 29.1%) represented about 55% of the sample. In January 2016, the average district-level workforce density was 75.8 per 100 000 population (95% CI 65.9, 87.1), and was increasing at an annual rate of 8.0% (95% CI 6.00, 9.00) through January 2018. The annual growth rate declined to 3.0% (95% CI 2.00, 4.00) after January 2018. Two provinces, Maputo City and Maputo Province, with 268.3 (95% CI 186.10, 387.00) and 104.6 (95% CI 84.20, 130.00) health workers per 100 000 population, respectively, had the highest workforce density at baseline (2016). There were 3122 community health workers (CHW), of whom 72.8% were male, in January 2016. The average number of CHWs per 10 000 population was 1.33 (95% CI 1.11, 1.59) in 2016 and increased by 18% annually between January 2016 and January 2018. This trend reduced to 11% (95% CI 0.00, 13.00) after January 2018. The sex ratio was twice as high for all provinces in the central and northern regions relative to Maputo Province. Maputo City (OR: 0.34; 95% CI 0.32, 0.34) and Maputo Province (OR: 0.56; 95% CI 0.49, 0.65) reported the lowest sex ratio at the baseline. Encouragingly, important sex ratio improvements were observed after January 2018, particularly in the northern and central regions.

CONCLUSION

Mozambique made substantial progress in health workers' availability during the study period; however, with a critical slowdown after 2018. Despite the progress, meaningful shortages and distribution disparities persist.

Iranian medical students' tendency to migrate and its associated factors

BACKGROUND

Medical staff migration is one of the challenges for both developed and developing countries affecting society's health and welfare, which limits access to equity. Therefore, this study was designed and conducted to investigate the tendency to migrate and the factors affecting it among medical students of the Tehran University of medical sciences, Tehran, Iran, in 2019.

METHODS

This cross-sectional study was performed among 472 medical students using a valid questionnaire which was designed after reviewing the literature and using the opinions of experts. The tendency to migrate and its associated factors were analyzed and reported using the Pearson correlation test, independent t-test, one-way ANOVA test, Tukey post-hock test, and Kruskal-Wallis non-parametric test.

RESULTS

According to this study, the tendency to migrate was 6.13 ± 2.82 out of 10. While there was no significant relationship between age, marital status, medical educational phase and the tendency to migrate (p > 0.05); There was a significant relationship between willingness to migrate with variables of gender (p = 0.027), pre-university study region (p < 0.001), father's academic degree (p = 0.007), mother's academic degree (p < 0.001), having the relative abroad (p < 0.001), foreign trip experience (p < 0.001), foreign language skills (p < 0.001), number of published articles (p = 0.005) and Iran's National Elite Foundation membership (p = 0.039).

CONCLUSIONS

Females, elites, and those with higher socioeconomic state, previous exposure to foreign countries, the ability to speak foreign languages, and research activity are more likely to migrate. Considering the high tendency to migrate among Iranian medical students, urgent and severe strategies must be undertaken to solve this social and health problem.

Perspectives of Nonspecialists Delivering a Brief Depression Treatment in the United States: A Qualitative Investigation

BACKGROUND

Task sharing is an implementation strategy which increases access to services by training and supporting treatment delivery by nonspecialists. Such an approach has demonstrated effectiveness for depression and other mental health outcomes; however, few studies in high-income countries have examined nonspecialist providers' (NSPs) perspectives of the acceptability, feasibility, and appropriateness of delivering mental health interventions. We examine qualitative reports of NSPs experiences delivering a brief structured behavioral intervention for depression (called "Do More, Feel Better" [DMFB]) to adults aged 55 and older.

METHODS

All NSPs (N = 4, 100%) who delivered DMFB participated in a focus group to probe their perceptions of the acceptability, feasibility, and appropriateness of both the intervention and their delivery experience as NSPs. Two coders analyzed the qualitative data from focus groups using codebook thematic analysis.

RESULTS

NSPs perceived the intervention and delivery experience to be acceptable, feasible, and appropriate. Qualitative results provided insight into specific barriers and facilitators which may be important to consider when planning to implement task sharing. Themes that emerged from qualitative data included supervision being highly acceptable and feasible, appropriateness of the intervention for NSPs, and the feasibility of tailoring the intervention to patient participants. NSPs also expressed difficulty managing emotional investment in patients' success and providing therapy during a pandemic and racial violence in the US.

CONCLUSIONS

Our results can inform future implementation and sustainment of task sharing interventions to expand access to care.

Human Resources for Health in Haryana, India: What can be Done Better?

Introduction

Health systems in developing countries suffers from both input and productivity issues. We examined the status of three domains of human resources for health, i.e., availability and distribution, capacity and productivity, and motivation and job-satisfaction, of the health-care workforce employed in the public health system of Haryana, a North Indian state.

Methodology

The primary data were collected from 377 public health facilities and 1749 healthcare providers across 21 districts. The secondary data were obtained from government reports in the public domain. Bivariate and multivariate statistical techniques were used for evaluating district performances, making inter-district comparisons and identifying determinants of motivation and job-satisfaction of the clinical cadres.

Results

We found 3.6 core health-care workers (doctors, staff nurses, and auxiliary nurses-midwives) employed in the public health-care system per 10,000 population, ranging from 1.35 in Faridabad district to 6.57 in Panchkula district. Around 78% of the sanctioned positions were occupied. A number of inpatient hospitalizations per doctor/nurses per month were 17 at the community health center level and 29 at the district hospital level; however, significant differences were observed among districts. Motivation levels of community health workers (85%) were higher than clinical workforce (78%), while health system administrators had lowest motivation and job satisfaction levels. Posting at primary healthcare facility, contractual employment, and co-habitation with family at the place of posting were found to be the significant motivating factors.

Conclusions

A revamp of governance strategies is required to improve health-care worker availability and equitable distribution in the public health system to address the observed geographic variations. Efforts are also needed to improve the motivation levels of health system administrators, especially in poorly performing districts and reduce the wide gap with better-off districts.

Utility of the Right to Health for Addressing Skilled Health Worker Shortages in Low- and Middle-Income Countries

BACKGROUND

As a fundamental human right, the right to health (RTH) can influence state actors' behaviour towards health inequities. Human rights advocates have invoked the RTH in a collective demand for improved access to essential medicines in low- and middle-income countries (LMICs). Similarly, scholars have used the RTH as a framework for analysing health problems. However, its utility for addressing skilled health worker (SHW) shortages in LMICs has been understudied. Realising that SHW shortages occur due to existing push-and-pull factors within and between LMICs and high-income countries (HICs), we sought to answer the question: "how, why, and under what circumstance does the RTH offer utility for addressing SHW shortages in LMICs?"

METHODS

We conducted a realist synthesis of evidence identified through a systematic search of peer-reviewed articles in Embase, Global Health, Medline (Ovid), ProQuest - Health & Medical databases, Scopus (Elsevier), Web of Science (Clarivate), CINAHL (EBSCO), APAIS-Health, Health Systems Evidence and PDQ-EVIDENCE; as well as grey literature from Google Scholar.

RESULTS

We found that the RTH offers utility for addressing SHW shortages in LMICs through HIC state actors' concerns for their countries' reputational risk, recognition of their obligation to support health workforce strengthening in LMICs, and concerns for the cost implication. State actors in LMICs will respond to adopt programs inspired by the RTH when they are convinced that it offers tangible national benefits and are not overly burdened with ensuring its success. The socio-economic and institutional factors that constrain state actors' response include financial cost and sustainability of rights'-based options.

CONCLUSION

State and non-state actors can use the RTH as a resource for promoting collective action towards addressing SHW shortages in LMICs. It can also inform negotiations between state actors in LMICs and their HIC counterparts.

A systematic review of strategies adopted to scale up COVID-19 testing in low-, middle- and high-income countries

OBJECTIVE

We undertook a systematic review of strategies adopted to scale up COVID-19 testing in countries across income levels to identify successful approaches and facilitate learning.

METHODS

Scholarly articles in English from PubMed, Google scholar and Google search engine describing strategies used to increase COVID-19 testing in countries were reviewed. Deductive analysis to allocate relevant text from the reviewed publications/reports to the a priori themes was done.

MAIN RESULTS

The review covered 32 countries, including 11 high-income, 2 upper-middle-income, 13 lower-middle-income and 6 low-income countries. Most low- and middle-income countries (LMICs) increased the number of laboratories available for testing and deployed sample collection and shipment to the available laboratories. The high-income countries (HICs) that is, South Korea, Germany, Singapore and USA developed molecular diagnostics with accompanying regulatory and legislative framework adjustments to ensure the rapid development and use of the tests. HICs like South Korea leveraged existing manufacturing systems to develop tests, while the LMICs leveraged existing national disease control programmes (HIV, tuberculosis, malaria) to increase testing. Continent-wide, African Centres for Disease Control and Prevention-led collaborations increased testing across most African countries through building capacity by providing testing kits and training.

CONCLUSION

Strategies taken appear to reflect the existing systems or economies of scale that a particular country could leverage. LMICs, for example, drew on the infectious disease control programmes already in place to harness expertise and laboratory capacity for COVID-19 testing. There however might have been strategies adopted by other countries but were never published and thus did not appear anywhere in the searched databases.

We know but we hope: A qualitative study of the opinions and experiences on the inclusion of management, health economics and research in the medical curriculum

The achievement of global and national health goals requires a health workforce that is sufficient and trained. Despite considerable steps in medical education, the teaching of management, health economics and research skills for medical doctors are often neglected in medical curricula. This study explored the opinions and experiences of medical doctors and academic educationalists on the inclusion of management, health economics and research in the medical curriculum. A qualitative study was undertaken at four medical schools in Southern Africa (February to April 2021). The study population was medical doctors and academic educationalists. Semi-structured interviews with purposively sampled participants were conducted. All interviews were recorded and professionally transcribed. Constructivist grounded theory guided the analysis with the use of ATLAS.ti version 9.1.7.0 software. In total, 21 academic educationalists and 28 medical doctors were interviewed. In the first theme We know, participants acknowledged the constraints of medical schools but were adamant that management needed to be taught intentionally and explicitly. The teaching and assessment of management and health economics was generally reported to be ad hoc and unstructured. There was a desire that graduates are able to use, but not necessarily do research. In comparison to management and research, support for the inclusion of health economics in the curriculum was insignificant. Under We hope, educationalists hoped that the formal clinical teaching will somehow instil values and best practices of management and that medical doctors would become health advocates. Most participants wished that research training could be optimised, especially in relation to the duration of allocated time; the timing in the curriculum and the learning outcomes. Despite acknowledgement that management and research are topics that need to be taught, educationalists appeared to rely on chance to teach and assess management in particular. These qualitative study findings will be used to develop a discrete choice experiment to inform optimal curricula design.

Management of human resources for health: implications for health systems efficiency in Kenya

Background

Human resources for health consume a substantial share of healthcare resources and determine the efficiency and overall performance of health systems. Under Kenya’s devolved governance, human resources for health are managed by county governments. The aim of this study was to examine how the management of human resources for health influences the efficiency of county health systems in Kenya.

Methods

We conducted a case study using a mixed methods approach in two purposively selected counties in Kenya. We collected data through in-depth interviews (n = 46) with national and county level HRH stakeholders, and document and secondary data reviews. We analyzed qualitative data using a thematic approach, and quantitative data using descriptive analysis.

Results

Human resources for health in the selected counties was inadequately financed and there were an insufficient number of health workers, which compromised the input mix of the health system. The scarcity of medical specialists led to inappropriate task shifting where nonspecialized staff took on the roles of specialists with potential undesired impacts on quality of care and health outcomes. The maldistribution of staff in favor of higher-level facilities led to unnecessary referrals to higher level (referral) hospitals and compromised quality of primary healthcare. Delayed salaries, non-harmonized contractual terms and incentives reduced the motivation of health workers. All of these effects are likely to have negative effects on health system efficiency.

Conclusions

Human resources for health management in counties in Kenya could be reformed with likely positive implications for county health system efficiency by increasing the level of funding, resolving funding flow challenges to address the delay of salaries, addressing skill mix challenges, prioritizing the allocation of health workers to lower-level facilities, harmonizing the contractual terms and incentives of health workers, and strengthening monitoring and supervision.

A systematic review of healthcare provider-targeted mobile applications for non-communicable diseases in low- and middle-income countries

Mobile health (mHealth) interventions hold promise for addressing the epidemic of noncommunicable diseases (NCDs) in low- and middle-income countries (LMICs) by assisting healthcare providers managing these disorders in low-resource settings. We aimed to systematically identify and assess provider-facing mHealth applications used to screen for, diagnose, or monitor NCDs in LMICs. In this systematic review, we searched the indexing databases of PubMed, Web of Science, and Cochrane Central for studies published between January 2007 and October 2019. We included studies of technologies that were: (i) mobile phone- or tablet-based, (ii) able to screen for, diagnose, or monitor an NCD of public health importance in LMICs, and (iii) targeting health professionals as users. We extracted disease type, intervention purpose, target population, study population, sample size, study methodology, technology stage, country of development, operating system, and cost. Our initial search retrieved 13,262 studies, 315 of which met inclusion criteria and were analyzed. Cardiology was the most common clinical domain of the technologies evaluated, with 89 publications. mHealth innovations were predominantly developed using Apple's iOS operating system. Cost data were provided in only 50 studies, but most technologies for which this information was available cost less than 20 USD. Only 24 innovations targeted the ten NCDs responsible for the greatest number of disability-adjusted life years lost globally. Most publications evaluated products created in high-income countries. Reported mHealth technologies are well-developed, but their implementation in LMICs faces operating system incompatibility and a relative neglect of NCDs causing the greatest disease burden.

Assessment of staffing needs for registered nurses and licensed practical nurses at primary care units in Brazil using Workload Indicators of Staffing Need (WISN) method

BACKGROUND

The balance between supply and demand for primary health care (PHC) services is one of the main challenges to the health system in Brazil. In this context, the application of planning methods could benefit the decision-making process for human resources organizations. Hence, the objective of this study was to assess the staffing needs for registered nurses (RNs) and licensed practical nurses (LPNs) at PHC services using the WISN method.

METHODS

The Workload Indicators of Staffing Need (WISN) methodology was applied at 13 Primary Care Units (PCU) located in the city of São Paulo, Brazil. It included 87 RNs and 174 LPNs, and used data from 2017 to 2019.

RESULTS

The WISN results found that RNs were under high workload pressure at 10 PCUs (77%) in 2017 and 2018, with a decrease to 8 PCUs (61%) in 2019. For LPNs, high workload pressure increased from 2 PCUs (15%) in 2017 to 13 PCUs (100%) in 2018, with a decrease to 11 (85%) in 2019.

CONCLUSION

The assessment of staffing needs for RNs and LPNs at the PCUs included in the study identified a consistent deficit in the number of professionals, and high workload pressure in most services throughout the study period.

Needs-led human resource planning for Sierra Leone in support of oral health

BACKGROUND

In Sierra Leone (SL), a low-income country in West Africa, dental care is very limited, largely private, and with services focused in the capital Freetown. There is no formal dental education. Ten dentists supported by a similar number of dental care professionals (DCPs) serve a population of over 7.5 million people. The objective of this research was to estimate needs-led requirements for dental care and human resources for oral health to inform capacity building, based on a national survey of oral health in SL.

METHODS

A dedicated operational research (OR) decision tool was constructed in Microsoft Excel to support this project. First, total treatment needs were estimated from our national epidemiological survey data for three key ages (6, 12 and 15 years), collected using the 'International Caries Classification and Management System (ICCMS)' tool. Second, oral health needs were extrapolated to whole population levels for each year-group, based on census demographic data. Third, full time equivalent (FTE) workforce capacity needs were estimated for mid-level providers in the form of Dental Therapists (DTs) and non-dental personnel based on current oral disease management approaches and clinical timings for treatment procedures. Fourth, informed by an expert panel, three oral disease management scenarios were explored for the national population: (1) Conventional care (CC): comprising oral health promotion (including prevention), restorations and tooth extraction; (2) Surgical and Preventive care (S5&6P and S6P): comprising oral health promotion (inc. prevention) and tooth extraction (D5 and D6 together, & at D6 level only); and (3) Prevention only (P): consisting of oral health promotion (inc. prevention). Fifth, the findings were extrapolated to the whole population based on demography, assuming similar levels of treatment need.

RESULTS

To meet the needs of a single year-group of childrens' needs, an average of 163 DTs (range: 133-188) would be required to deliver Conventional care (CC); 39 DTs (range: 30-45) to deliver basic Surgical and Preventive care (S6P); 54 DTs for more extended Surgical and Preventive care (S5&6P) (range 38-68); and 27 DTs (range: 25-32) to deliver Prevention only (P). When scaled up to the total population, an estimated 6,147 DTs (range: 5,565-6,870) would be required to deliver Conventional care (CC); 1,413 DTs (range: 1255-1438 DTs) to deliver basic Surgical and Preventive care (S6P); 2,000 DTs (range 1590-2236) for more extended Surgical and Preventive care (S5&6P) (range 1590-2236); and 1,028 DTs to deliver Prevention only (P) (range: 1016-1046). Furthermore, if oral health promotion activities, including individualised prevention, could be delivered by non-dental personnel, then the remaining surgical care could be delivered by 385 DTs (range: 251-488) for the S6P scenario which was deemed as the minimum basic baseline service involving extracting all teeth with extensive caries into dentine. More realistically, 972 DTs (range: 586-1179) would be needed for the S5&6P scenario in which all teeth with distinctive and extensive caries into dentine are extracted.

CONCLUSION

The study demonstrates the huge dental workforce needs required to deliver even minimal oral health care to the Sierra Leone population. The gap between the current workforce and the oral health needs of the population is stark and requires urgent action. The study also demonstrates the potential for contemporary epidemiological tools to predict dental treatment needs and inform workforce capacity building in a low-income country, exploring a range of solutions involving mid-level providers and non-dental personnel.

Inequalities in the distribution of the general practice workforce in England: a practice-level longitudinal analysis

Background

In England, demand for primary care services is increasing and GP shortages are widespread. Recently introduced primary care networks (PCNs) aim to expand the use of additional practice-based roles such as physician associates (PAs), pharmacists, paramedics, and others through financial incentives for recruitment of these roles. Inequalities in general practice, including additional roles, have not been examined in recent years, which is a meaningful gap in the literature. Previous research has found that workforce inequalities are associated with health outcome inequalities.

Aim

To examine recent trends in general practice workforce inequalities.

Design & setting

A longitudinal study using quarterly General Practice Workforce datasets from 2015–2020 in England.

Method

The slope indices of inequality (SIIs) for GPs, nurses, total direct patient care (DPC) staff, PAs, pharmacists, and paramedics per 10 000 patients were calculated quarterly, and plotted over time, with and without adjustment for patient need.

Results

Fewer GPs, total DPC staff, and paramedics per 10 000 patients were employed in more deprived areas. Conversely, more PAs and pharmacists per 10 000 patients were employed in more deprived areas. With the exception of total DPC staff, these observed inequalities widened over time. The unadjusted analysis showed more nurses per 10 000 patients employed in more deprived areas. These values were not significant after adjustment but approached a more equal or pro-poor distribution over time.

Conclusion

Significant workforce inequalities exist and are even increasing for several key general practice roles, with workforce shortages disproportionately affecting more deprived areas. Policy solutions are urgently needed to ensure an equitably distributed workforce and reduce health inequities.

Incentive preferences for community health volunteers in Kenya: findings from a discrete choice experiment

BACKGROUND

Community health volunteers (CHVs) play crucial roles in enabling access to healthcare at the community levels. Although CHVs are considered volunteers, programmes provide financial and non-financial incentives. However, there is limited evidence on which bundle of financial and non-financial incentives are most effective for their improved performance.

METHODS

We used a discrete choice experiment (DCE) to understand incentive preferences of CHVs with the aim to improve their motivation, performance and retention. Relevant incentive attributes were identified through qualitative interviews with CHVs and with their supervisors. We then deployed a nominal group technique to generate and rank preferred attributes among CHVs. We developed a DCE based on the five attributes and administered it to 211 CHVs in Kilifi and Bungoma counties in Kenya. We used mixed multinomial logit models to estimate the utility of each incentive attribute and calculated the trade-offs the CHWs were willing to make for a change in stipend.

RESULTS

Transport was considered the incentive attribute with most relative importance followed by tools of trade then monthly stipend. CHVs preferred job incentives that offered higher monthly stipends even though it was not the most important. They had negative preference for job incentives that provided award mechanisms for the best performing CHVs as compared with jobs that provided recognition at the community level and preferred job incentives that provided more tools of trade compared with those that provided limited tools.

CONCLUSION

A bundled incentive of both financial and non-financial packages is necessary to provide a conducive working environment for CHVs. The menu of options relevant for CHVs in Kenya include transport, tools of trade and monthly stipend. Policy decisions should be contextualised to include these attributes to facilitate CHW satisfaction and performance.

Elusive quality: the challenges and ethical dilemmas faced by international non-governmental organisations in sourcing quality assured medical products

Although medical products that are of sound quality are fundamental to the delivery of healthcare, so too is their availability, affordability, accessibility and acceptability. However, achieving all of these aims consistently and simultaneously may be unfeasible due to a host of barriers—no matter the country. If uncertainty, constraints and conflicting priorities also threaten their delivery, not only does the situation becomes yet more challenging, the morally just course of action becomes yet more opaque. While global health organisations, supply chains and projects are heterogenous, international non-governmental organisations (iNGOs) responding to humanitarian crises or delivering development assistance in low-income and middle-income countries are undoubtedly prone to this issue. In a novel framing of the problem of substandard and falsified medicines, this article explores some ethical dilemmas that, directly or indirectly, could result in the quality of medical products in iNGO health projects to be compromised. Drawing on a broad literature base and years of experience as a senior humanitarian pharmacist, the author reflects on the barriers, culture and system that contributes to the existence and persistence of substandard and falsified medical products in global assistance projects. The paper offers an in-depth examination of pressures that may arise in four key areas (capacity, supply chain, bureaucracy and quality assurance) and postulates on the myriad ways in which this may alter the attitudes, behaviours and decision-making of iNGOs in a manner that disincentivises the prioritisation of medical product quality. This paper does not seek to excoriate the aid sector, but rather to lend a new perspective: that such predicaments are overlooked, real-world ethical dilemmas in urgent need of greater openness, research, debate and guidance, for the benefit of moral decision-making and patient care.

Senior Managers' Experience with Health, Happiness, and Motivation in Hospitals and the Perceived Impact on Health Systems: The Case of Meru County, Kenya

Hospitals play a significant role in health systems. Studies among the health workforce have revealed their experiences with mental health challenges. In comparison, there is limited literature on their positive mental health. The purpose of this study was to explore senior managers’ experiences with health status, happiness, and motivation in hospitals and the perceived impact on the health system in Kenya. This qualitative study applied a phenomenological research design. Senior managers within the hospital management teams were selected using purposive sampling. Semi-structured interviews were carried out among senior managers across eleven hospitals in Meru County, Kenya. Among the eleven participants 63.6% were female and 36.4%, were male and the mean age was 44.5 years. The audio-taped data were transcribed and analyzed using Colaizzi’s phenomenological approach. The five themes revealed were: (1) Happiness in the health system; (2) Health status in the health system; (3) Motivation in the health system; (4) Challenges in the health system; (5) Possible solutions to the challenges in the health system. This study revealed the positive and negative impact of the three domains, challenges, and solutions, from the senior managers’ perspective. Healthy, happy, and motivated senior managers and healthcare workers are more responsive and perform better. Policy interventions and programs promoting happiness, health status, and motivation are necessary for strengthening the health workforce and health system.

Exploring factors influencing the retention of nurses in a religious hospital in Taiwan: a cross-sectional quantitative study

Background

Long-term deficits in the nursing labor force and high turnover rates are common in the Taiwanese medical industry. Little research has investigated the psychological factors associated with the retention of nursing staff. However, in practice, religious hospitals often provide nursing staff with education in medicine or the medical humanities to enhance their psychological satisfaction. The objective of this study was to explore factors influencing nursing staff retention in their work in relation to different levels of needs. A further objective was to investigate whether medical humanities education was associated with the retention of nursing staff.

Methods

This study used self-administrated questionnaires to survey nurses working in northern areas of Taiwan. The questionnaire design was based on the six levels of Maslow’s hierarchy of needs. Participation was voluntary, and the participants signed informed consent documents. Self-administrated questionnaires were distributed to a total of 759 participants, and 729 questionnaires were returned (response rate 96.04%). Logistic regression analysis was used to estimate the impact of seniority on nurses’ reported intention to stay after adjustment for nurse characteristics (gender and age).

Results

In the Pearson correlation analysis, nurses’ willingness to stay was moderately correlated with “physical needs”, “safety needs”, “love and belonging needs”, and “esteem needs” (r = 0.559, P < 0.001; r = 0.533, P < 0.001; r = 0.393, P < 0.001; and r = 0.476, P < 0.001, respectively). Furthermore, nurses’ willingness to stay was highly correlated with “self-actualization needs”, “beyond self-actualization needs” and “medical humanities education-relevant needs” (r = 0.707, P < 0.001; r = 0.728, P < 0.001; and r = 0.678, P < 0.001, respectively). We found that the odds ratios (ORs) of retention of nursing staff with less than 1 year (OR = 4.511, P = 0.002) or 1–3 years (OR = 3.248, P = 0.003) of work experience were significantly higher than that of those with 5–10 years of work experience.

Conclusions

With regard to medical humanities education, we recommend adjusting training, as the compulsory activities included in the official programs are inadequate, and adjusting the number of required hours of medical humanities education. Tailoring different educational programs to different groups (especially nurses who have worked 3–5 years or 5–10 years in the case study hospital) might improve acceptance by nursing staff.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-021-00558-7.

Community-based postnatal care services for women and newborns in Kenya: an opportunity to improve quality and access?

Background

In resource-constrained settings, Community Health Workers (CHWs) are the first point of contact between communities and the health system, as providers of maternal and newborn health services. However, little is known of the quality of community-based postnatal care (PNC). We assessed the content of PNC provided by CHWs and women’s experiences of care in two Kenyan counties.

Methods

We used a cross-sectional, mixed methods design to examine the quality of PNC services provided by CHWs. Trained observers attended PNC home visits to assess technical quality using a 25-item checklist covering four PNC domains: infant health warning signs, maternal health warning signs, essential newborn care, and breastfeeding. The observers completed an 8-item communication quality checklist. We conducted follow-up surveys with observed PNC clients to assess their experiences of care. Finally, we used in-depth interviews with CHWs and focus group discussions with observed PNC clients to understand the experiential quality of care.

Results

Observations suggest shortcomings in the technical quality of PNC home visits. CHWs completed an average of 6.4 (standard deviation SD = 4.1) of the 25 PNC technical quality items. CHWs often lacked essential supplies, and only six percent carried all four of the CHW job aids and tools specified in the national guidelines for maternal health at community level. However, CHWs completed an average of 7.3 (SD = 1.1) of the 8 communication quality items, and most PNC clients (88%) reported being satisfied during follow-up interviews. Higher technical quality scores were associated with older mothers, better communication, longer visit duration, and CHWs who carried at least three job tools. CHWs expressed a strong sense of responsibility for care of their clients, while clients underscored how CHWs were trusted to maintain their clients’ confidentiality and were a valuable community resource.

Conclusion

This study identified gaps in the technical quality of CHW PNC practices, while also recognizing positive elements of experiential quality of care, including communication quality, and trusting relationships. This study also demonstrated the strength of the CHWs’ role in establishing linkages between the community and facilities, as long as the CHW are perceived as, and enabled to be, an integral part of the PHC network in Kenya.

Predictors of Health-Related Quality of Life among Healthcare Workers in the Context of Health System Strengthening in Kenya

Kenya is among the countries with an acute shortage of skilled health workers. There have been recurrent health worker strikes in Kenya due to several issues, some of which directly or indirectly affect their health. The purpose of this study was to investigate the predictors of health-related quality of life (HRQOL) among healthcare workers in public and mission hospitals in Meru County, Kenya. A cross-sectional study design was undertaken among 553 healthcare workers across 24 hospitals in Meru County. The participants completed the EuroQol-five dimension-five level (EQ-5D-5L) instrument, which measures health status across five dimensions and the overall self-assessment of health status on a visual analogue scale (EQ-VAS). Approximately 66.55% of the healthcare workers reported no problems (i.e., 11,111) across the five dimensions. The six predictors of HRQOL among the healthcare workers were hospital ownership (p < 0.05), age (p < 0.05), income (p < 0.01), availability of water for handwashing (p < 0.05), presence of risk in using a toilet facility (p < 0.05), and overall safety of hospital work environment (p < 0.05). Personal, job-related attributes and work environment characteristics are significant predictors of healthcare workers HRQOL. Thus, these factors ought to be considered by health policymakers and managers when developing and implementing policies and programs aimed at promoting HRQOL among healthcare workers.

Examining the motivations and future career aspirations of Qatari pharmacy students and alumni: A case study

INTRODUCTION

The Global Pharmacy Workforce report published by the International Pharmaceutical Federation indicated pharmacy workforce shortages and called forstrengthening workforce planning. The low percentage of Qatari students in the College of Pharmacy at Qatar University could negatively impact the fulfilment of the Qatar National Vision and the United Nations' Goals. The aim of this research is to examine the motivations of Qatari pharmacy students and alumni to study pharmacy, and to understand their perceptions of the profession and career aspirations.

METHODS

A qualitative case study research was conducted. Data were collected by focus groups and semi-structured interviews, and were analysed thematically.

RESULTS

Research findings suggested that increasing the national workforce was the main motive for students to study pharmacy. The participants' perceptions of the profession varied from pharmacy being a drug sales profession to it being a healthcare profession. Participants' career aspirations included pursuing graduate studies, working in hospitals, and working in academia. The participants were generally satisfied with studying pharmacy, which encouraged them to recommend the major to others. However, the participants were challenged by the lack of societal recognition of pharmacy and by misperceptions about Qatari students, which motivated them to further demonstrate their competencies.

CONCLUSIONS

This study will facilitate the understanding of factors that motivate and demotivate Qatari students from joining the pharmacy major and their career aspirations, which will ultimately enhance the development of recruitment strategies geared towards attracting a larger number of qualified and highly motivated Qataris into the pharmacy profession.

Prevalence and determinants of breast cancer screening in four sub-Saharan African countries: a population-based study

OBJECTIVES

Breast cancer is the most prevalent cancer and the second leading cause of cancer-related deaths among women after cervical cancer in much of sub-Saharan Africa. This study aims to examine the prevalence and sociodemographic-socioeconomic factors associated with breast cancer screening among women of reproductive age in sub-Saharan Africa.

DESIGN

A weighted population-based cross-sectional study using Demographic and Health Surveys (DHS) data. We used all available data on breast cancer screening from the DHS for four sub-Saharan African countries (Burkina Faso, Ivory Coast, Kenya and Namibia). Breast cancer screening was the outcome of interest for this study. Multivariable Poisson regression was used to identify independent factors associated with breast cancer screening.

SETTING

Four countries participating in the DHS from 2010 to 2014 with data on breast cancer screening.

PARTICIPANTS

Women of reproductive age 15-49 years (N=39 646).

RESULTS

The overall prevalence of breast cancer screening was only 12.9% during the study period, ranging from 5.2% in Ivory Coast to 23.1% in Namibia. Factors associated with breast cancer screening were secondary/higher education with adjusted prevalence ratio (adjusted PR)=2.33 (95% CI: 2.05 to 2.66) compared with no education; older participants, 35-49 years (adjusted PR=1.73, 95% CI : 1.56 to 1.91) compared with younger participants 15-24 years; health insurance coverage (adjusted PR=1.57, 95% CI: 1.47 to 1.68) compared with those with no health insurance and highest socioeconomic status (adjusted PR=1.33, 95% CI : 1.19 to 1.49) compared with lowest socioeconomic status.

CONCLUSION

Despite high breast cancer mortality rates in sub-Saharan Africa, the prevalence of breast cancer screening is substantially low and varies gradually across countries and in relation to factors such as education, age, health insurance coverage and household wealth index level. These results highlight the need for increased efforts to improve the uptake of breast cancer screening in sub-Saharan Africa.

Determinants of Motivation among Healthcare Workers in the East African Community between 2009-2019: A Systematic Review

Healthcare workers are an essential element in the functionality of the health system. However, the health workforce impact on health systems tends to be overlooked. Countries within the Sub-Saharan region such as the six in the East African Community (EAC) have weak and sub-optimally functioning health systems. As countries globally aim to attain Universal Health Coverage and the Sustainable Development Goal 3, it is crucial that the significant role of the health workforce in this achievement is recognized. In this systematic review, we aimed to synthesise the determinants of motivation as reported by healthcare workers in the EAC between 2009 and 2019. A systematic search was performed using four databases, namely Cochrane library, EBSCOhost, ProQuest and PubMed. The eligible articles were selected and reviewed based on the authors' selection criteria. A total of 30 studies were eligible for review. All six countries that are part of the EAC were represented in this systematic review. Determinants as reported by healthcare workers in six countries were synthesised. Individual-level-, organizational/structural- and societal-level determinants were reported, thus revealing the roles of the healthcare worker, health facilities and the government in terms of health systems and the community or society at large in promoting healthcare workers' motivation. Monetary and non-monetary determinants of healthcare workers' motivation reported are crucial for informing healthcare worker motivation policy and health workforce strengthening in East Africa.

Seeking care in the context of social health insurance in Kenya and Ghana

BACKGROUND

Social Health Insurance (SHI) is widely used by countries attempting to move toward Universal Health Coverage (UHC). While evidence suggests that SHI is a promising strategy for achieving UHC, low-income countries often struggle to implement and sustain SHI systems. It is therefore important to understand how SHI enrollees use health insurance and how it affects their health-seeking behavior. This paper examines how SHI affects patient decision-making regarding when and where to seek care in Kenya and Ghana, two countries with established SHI systems in sub-Saharan Africa.

METHODS

This paper draws from two datasets collected under the African Health Markets for Equity (AHME) program. One dataset, collected in 2013 and 2017 as part of the AHME qualitative evaluation, consists of 106 semi-structured clinic exit interviews conducted with patients in Ghana and Kenya. This data was analyzed using an inductive, thematic approach. The second dataset was collected internally by the AHME partner organizations. It derives from a cross-sectional survey of social franchise clients at three social franchise networks supported by AHME. Data collection took place from February - May 2018 and in December 2018.

RESULTS

Many clients appreciated that insurance coverage made healthcare more affordable, reported seeking care more frequently when covered with SHI. Clients also noted that the coverage gave them access to a wider variety of providers, but rarely sought out SHI-accredited providers specifically. However, clients sometimes were charged for services that should have been covered by insurance. Due to a lack of understanding of SHI benefits, clients rarely knew they had been charged inappropriately.

CONCLUSIONS

Clients and providers would benefit from education on what is included in the SHI package. Providers should be monitored and held accountable for charging clients inappropriately; in Ghana this should be accompanied by reforms to make government financing for SHI sustainable. Since clients valued provider proximity and both Kenya and Ghana have a dearth of providers in rural areas, both countries should incentivize providers to work in these areas and prioritize accrediting rural facilities into SHI schemes to increase accessibility and reach.

Availability of eye care infrastructure and human resources for managing diabetic retinopathy in the western province of Sri Lanka

Purpose:

Blindness and visual impairment due to diabetic retinopathy (DR) are avoidable by early screening and timely treatment. The western province of Sri Lanka has the highest prevalence of diabetes mellitus (18.6%) in the country. DR had been given less attention in services expansion because of lack of evidence. The aim of this study was to assess the availability of human resources (HR) and infrastructure for DR in eye care facilities.

Methods:

A cross-sectional survey was conducted in 51 health care institutions by administering a validated questionnaire schedule and through semi-structured interviews. The data on infrastructure, HR and level of training, and skills were collected during the site visits by observation, frequency counting, and interviewing. Key findings of the interviews were recorded using categorical responses. Data analysis was done using MS-Excel^® and STATA/IC^®-Version 2-13.0 packages.

Results:

The response rate of the survey was 84.3% (43/51). There were 40 board-certified ophthalmologists and 6 vitreo-retinal surgeons in the region, of whom 77.5% (31/40) were in Colombo district. The highest population-adjusted DR-related infrastructure ratios were recorded from Colombo district. Mid-level cadres such as medical officers' mean skill score of DR screening and treatment was low (0.37, 95% CI 0.32-0.40).

Conclusion:

There is no systematic DR screening program, and HR and infrastructure distribution was not aligned to the population need in the western province. Urgent attention should be paid to expand the service delivery and mid-level HR training for DR screening and treatment in this region.

Utilization of breast cancer screening in Kenya: what are the determinants?

BACKGROUND

Breast cancer accounts for 23% of all cancer cases among women in Kenya. Although breast cancer screening is important, we know little about the factors associated with women's breast cancer screening utilization in Kenya. Using the Andersen's behavioural model of health care utilization, we aim to address this void in the literature.

METHODS

We draw data on the Kenya Demographic and Health Survey and employ univariate, bivariate, and multivariate analyses.

RESULTS

We find that women's geographic location, specifically, living in a rural area (OR = 0.89; p < 0.001) and the North Eastern Province is associated with lower odds of women being screened for breast cancer. Moreover, compared to the more educated, richer and insured, women who are less educated, poorer, and uninsured (OR = 0.74; p < 0.001) are less likely to have been screened for breast cancer.

CONCLUSION

Based on these findings, we recommend place and group-specific education and interventions on increasing breast cancer screening in Kenya.

Health system factors influencing uptake of Human Papilloma Virus (HPV) vaccine among adolescent girls 9-15 years in Mbale District, Uganda

Background

Globally, cervical cancer is the fourth most common cancer in women with more than 85% of the burden in developing countries. In Uganda, cervical cancer has shown an increase of 1.8% per annum over the last 20 years. The availability of the Human Papillomavirus (HPV) vaccine presents an opportunity to prevent cervical cancer. Understanding how the health system influences uptake of the vaccine is critical to improve it. This study aimed to assess how the health systems is influencing uptake of HPV vaccine so as to inform policy for vaccine implementation and uptake in Mbale district, Eastern Uganda.

Methods

We conducted a cross sectional study of 407 respondents, selected from 56 villages. Six key informant interviews were conducted with District Health Officials involved in implementation of the HPV vaccine. Quantitative data was analyzed using Stata V.13. Prevalence ratios with their confidence intervals were reported. Qualitative data was audio recorded, transcribed verbatim and analyzed using MAXQDA V.12, using the six steps of thematic analysis developed by Braun and Clarke.

Results

Fifty six (14%) of 407 adolescents self-reported vaccine uptake. 182 (52.3%) of 348 reported lack of awareness about the HPV vaccine as the major reason for not having received it. Receiving vaccines from outreach clinics (p = 0.02), having many options from which to receive the vaccine (p = 0.02), getting an explanation on possible side-effects (p = 0.024), and receiving the vaccine alongside other services (p = 0.024) were positively associated with uptake.

Key informants reported inconsistency in vaccine supply, inadequate training on HPV vaccine, and the lack of a clear target for HPV vaccine coverage as the factors that contribute to low uptake.

Conclusion

We recommend training of health workers to provide adequate information on HPV vaccine, raising awareness of the vaccine in markets, schools, and radio talk shows, and communicating the target to health workers.

Uptake of the HPV vaccine was lower than the Ministry of Health target of 80%. We recommend training of health workers to clearly provide adequate information on HPV vaccine, increasing awareness about the vaccine to the adolescents and increasing access for girls in and out of school.

Barriers in the access, diagnosis and treatment completion for tuberculosis patients in central and western Nepal: A qualitative study among patients, community members and health care workers

Background

Nepal has achieved a significant reduction of TB incidence over the past decades. Nevertheless, TB patients continue to experience barriers in access, diagnosis and completion of the treatment. The main objective of this study was to explore the factors affecting the access to the health services, diagnosis and the treatment completion for TB patients in central and western Nepal.

Methods

Data were collected using in-depth interviews (IDI) with the TB patients (n = 4); Focus Group Discussions (FGDs) with TB suspected patients (n = 16); Semi Strucutred Interviews (SSIs) with health workers (n = 24) and traditional healers (n = 2); and FGDs with community members (n = 8). All data were audio recorded, transcribed and translated to English. All transcriptions underwent thematic analysis using qualitative data analysis software: Atlas.ti.

Results

Barriers to access to the health centre were the long distance, poor road conditions, and costs associated with travelling. In addition, lack of awareness of TB and its consequences, and the belief, prompted many respondents to visit traditional healers. Early diagnosis of TB was hindered by lack of trained health personnel to use the equipment, lack of equipment and irregular presence of health workers. Additional barriers that impeded the adherence and treatment completion were the need to visit health centre daily for DOTS treatment and associated constraints, complex treatment regimen, and the stigma.

Conclusions

Barriers embedded in health services and care seekers’ characteristics can be dealt by strengthening the peripheral health services. A continuous availability of (trained) human resources and equipment for diagnosis is critical. As well as increasing the awareness and collaborating with the traditional healers, health services utilization can be enhanced by compensating the costs associated with it, including the modification in current DOTS strategy by providing medicine for a longer term under the supervision of a family member, peer or a community volunteer.

Who will protect the health of rural residents in China if village doctors run out?

This paper discusses the current situation of Chinese village doctors and highlights the importance of increasing the number of village doctors for better health service and a stronger health system. This study reviewed relevant health policies and data from the Chinese Statistic Year Book 2016 to assess the current status of Chinese village doctors and clinics. The Chinese government has launched a set of healthcare reforms to strengthen primary health care (PHC), especially in rural areas. However, the recruitment and retention of village doctors has not been successful. The analysis of available data suggests that fewer doctors or graduated medical students want to work in village clinics and provide services for rural residents. It is widely recognised in China and other countries that a good PHC system protects the population's health at low cost. To achieve a better health system, the Chinese government should strengthen PHC, expanding the village clinics' coverage to improve access to PHC and basic public health, and introduce more sustainable policies to attract more PHC practitioners to Chinese villages.

Self-care habits among people who inject drugs with skin and soft tissue infections: a qualitative analysis

BACKGROUND

Injection drug use is on the rise in the USA, and skin and soft tissue infections (SSTI) are a common complication, resulting in significant morbidity and mortality. Due to structural barriers to care-seeking, many people who inject drugs avoid formal care and resort to self-care techniques, but little is known about the nature of these techniques, or more generally about the accuracy or breadth of this population's knowledge of SSTIs.

METHODS

Semi-structured qualitative interviews were conducted with 12 people who inject heroin in two metropolitan areas: Sacramento and Boston, USA.

RESULTS

These interviews reveal a robust and accurate knowledge base regarding skin infections, including the progression from simple cellulitis to an abscess, and acknowledgment of the possibility of serious infections. Nonetheless, there remains a reticence to seek care secondary to past traumatic experiences. A step-wise approach to self-care of SSTI infections was identified, which included themes of whole-body health, topical applications, use of non-prescribed antibiotics, and incision and drainage by non-medical providers.

CONCLUSIONS

The reported SSTI self-care strategies demonstrate resilience and ingenuity, but also raise serious concerns about inappropriate antibiotic consumption and complications of invasive surgical procedures performed without proper training, technique, or materials. Harm reduction agencies and health care providers should work to obviate the need for these potentially dangerous practices by improving healthcare access for this population. In the absence of robust solutions to meet the needs of this population, education materials should be developed to optimize the efficacy and minimize the harms of these practices, while empowering and supporting the autonomy of people who use drugs and providing clear guidance on when self-care should be abandoned in favor of formal medical care.

What made Lebanese emigrant nurses leave and what would bring them back? A cross-sectional survey

BACKGROUND

The nursing workforce is critical for the provision of quality health-care and positive patient outcomes. There is a global trend of migration of nurses from under-developed to developed countries due to attractive job offers in the host countries. Lebanon presents such a case where nurses are migrating abroad, leading to shortages in the nursing workforce in their home country.

OBJECTIVES

The aim of this study was to investigate reasons for the migration of Lebanese nurses, and incentives that would attract them back to their home country in order to enhance the nursing workforce in Lebanon.

DESIGN

This study is a cross-sectional survey of emigrant Lebanese nurses.

SETTINGS

Recipient countries where Lebanese nurses emigrated.

PARTICIPANTS

440 Emigrant Lebanese nurses were identified through the registration database of the Order of Nurses in Lebanon. The survey was sent to all of them via email; 153 responses were received.

METHODS

Data were collected from November 2017 to March 2018. Analysis included univariate and bivariate tests to present descriptive statistics of the respondents, and to examine region of residence and gender in relation to their current job satisfaction, reasons for leaving Lebanon, intention to return to Lebanon, and aspects that would attract them back to their home country. Logistic regression analysis was used to determine the socio-demographic and work-related characteristics associated with the odds of returning to practice nursing in Lebanon.

RESULTS

A total 136 completed responses were considered. Emigrant Lebanese nurses were highly educated, with more years of work experience, and older than nurses remaining in their home country. Top reasons for nurses to leave Lebanon included unsatisfactory salary or benefits, better work opportunities in other countries, and lack of professional development or career advancement. The majority of surveyed nurses (59%) expressed willingness to return to practice nursing in Lebanon. Aspects that would attract emigrant Lebanese nurses back to their home country include attractive salary or better benefits and opportunities for professional development, career advancement, or continuing education. Emigrant Lebanese nurses residing in the Gulf, staff nurses, and nurses with more years of work experience were more likely to return to practice nursing in Lebanon.

CONCLUSION

Highly educated and experienced nurses are departing from Lebanon. This presents a challenge for the less experienced nurses remaining in the country, who could benefit from the mentorship and experience of their migrating peers. Creating an environment that could enhance the professional development of nurses in Lebanon, with financial incentives could retain the nursing workforce in the country.

Patients with Disorders of Consciousness in India: Preliminary Results from a Pilot Survey

The epidemiological data of Indian patients with disorders of consciousness (DOC), specifically vegetative state and minimally conscious state, have not been investigated. The present study sought to explore the current state of the art in India for patients with DOC promoting a pilot survey. An ad hoc questionnaire was sent to a total of 400 Indian professionals who are affiliated to various centers; 59 professionals completed the questionnaire and 52 of them declared that their centers hospitalized patients with DOC in the last year for rehabilitation/medical treatments. The majority of the professionals were from Maharashtra region. The main preliminary findings showed that the prevalence rates of traumatic and nontraumatic etiologies were equally distributed, that the rate of use of the coma recovery scale-revised was low, and that the rehospitalization was always or frequently possible in neurological and rehabilitation units. The extrapolated estimated rate of patients with DOC hospitalized in the centers involved in 2017 was equal to 4 per million of population in Maharashtra region. More than 50% of the professionals declared that there were neither sufficient nor adequate services for caregivers’ support. Even if the present pilot survey has some limitations, the present article offers the first preliminary data on patients with DOC in Indian country.

Total per-visit medical expenses incurred by outpatients with diabetes-Evidence from six provinces in eastern China

BACKGROUND

Chronic diseases associated with diabetes threaten the health of Chinese people and contribute to poverty.

METHODS

Medical service utilization records of 78 124 visits by outpatients with diabetes to medical institutions in China's eastern region between 2013 and 2015 were randomly selected from the Medical Insurance Department (MID) database. One-way analysis of variance (ANOVA) was used to compare the average total per-visit, out-of-pocket (OOP), and medical insurance (MI) fund expenses between variables. Multiple linear regression analysis was performed to identify possible risk factors affecting total per-visit medical expenses.

RESULTS

Average total per-visit medical expenses were 244.59, 285.56, and 435.33 yuan in primary, secondary, and tertiary medical institutions, respectively. Significant differences were found for average total per-visit medical expenses by year of visit, age, type of medical insurance, and levels of medical institutions. No significant differences were found for average total per-visit medical expenses by gender.

CONCLUSION

The functions of medical networks at all levels should be clarified and the Urban Resident Basic Medical Insurance (URBMI) reimbursement ratio improved to ensure equal access to medical services irrespective of medical insurance type. Patients with chronic diseases should be encouraged to visit primary medical institutions to reduce medical expenses.

What Happens When Donors Pull Out? Examining Differences in Motivation Between Health Workers Who Recently Had Performance-Based Financing (PBF) Withdrawn With Workers Who Never Received PBF in the Democratic Republic of Congo

Background: A motivated workforce is necessary to ensure the delivery of high quality health services. In developing countries, performance-based financing (PBF) is often employed to increase motivation by providing financial incentives linked to performance. However, given PBF schemes are usually funded by donors, their long-term financing is not always assured, and the effects of withdrawing PBF on motivation are largely unknown. This cross-sectional study aimed to identify differences in motivation between workers who recently had donor-funded PBF withdrawn, with workers who had not received PBF.

Methods: Quantitative data were collected from 485 health workers in 5 provinces using a structured survey containing questions on motivation which were based on an established motivation framework. Confirmatory factor analysis was used to verify dimensions of motivation, and multiple regression to assess differences in motivation scores between workers who had previously received PBF and those who never had. Qualitative interviews were also carried out in Kasai Occidental province with 16 nurses who had previously or never received PBF.

Results: The results indicated that workers in facilities where PBF had been removed scored significantly lower on most dimensions of motivation compared to workers who had never received PBF. The removal of the PBF scheme was blamed for an exodus of staff due to the dramatic reduction in income, and negatively impacted on relationships between staff and the local community.

Conclusion: Donors and governments unable to sustain PBF or other donor-payments should have clear exit strategies and institute measures to mitigate any adverse effects on motivation following withdrawal.

Quality of care during childbirth at public health facilities in Bangladesh: a cross-sectional study using WHO/UNICEF 'Every Mother Every Newborn (EMEN)' standards

Background

This manuscript presents findings from a baseline assessment of health facilities in Bangladesh prior to the implementation of the ‘Every Mother Every Newborn Quality Improvement’ initiative.

Methodology

A cross-sectional survey was conducted between June and August 2016 in 15 government health facilities. Structural readiness was assessed by observing the physical environment, the availability of essential drugs and equipment, and the functionality of the referral system. Structured interviews were conducted with care providers and facility managers on human resource availability and training in the maternal and newborn care. Observation of births, reviews of patient records and exit interviews with women who were discharged from the selected health facilities were used to assess the provision and experience of care.

Results

Only six (40%) facilities assessed had designated maternity wards and 11 had newborn care corners. There were stock-outs of emergency drugs including magnesium sulfate and oxytocin in nearly all facilities. Two-thirds of the positions for medical officers was vacant in district hospitals and half of the positions for nurses was vacant in subdistrict facilities. Only 60 (45%) healthcare providers interviewed received training on newborn complication management. No health facility used partograph for labour monitoring. Blood pressure was not measured in half (48%) and urine protein in 99% of pregnant women. Only 27% of babies were placed skin to skin with their mothers. Most mothers (97%) said that they were satisfied with the care received, however, only 46% intended on returning to the same facility for future deliveries.

Conclusions

Systematic implementation of quality standards to mitigate these gaps in service readiness, provision and experience of care is the next step to accelerate the country’s progress in reducing the maternal and neonatal deaths.

Competency building for lay health workers is an intangible force driving basic public health services in Southwest China

BACKGROUND

Providing universal basic public health services (BPHS) for residents is the main goal of the new health reform in China. Lay health workers (LHWs) in primary health care (PHC) sectors play key roles in BPHS delivery. The competency of LHWs is critical to quality BPHS. This study assessed LHWs' competency to deliver BPHS and related training in resource-limited Southwest China.

METHODS

A mixed research method combining in-depth interviews with secondary data collection was used to collect data in this cross-sectional study. Fifty-four LHWs and 16 leaders in 16 PHC sectors were recruited for in-depth interviews. Secondary data on 198 LHWs were collected through standard forms.

RESULTS

Both the interviews and secondary data suggested that all PHC sectors did not have sufficient LHWs and lacked qualified LHWs to deliver BPHS overall, particularly in relatively low economic rural areas in Guizhou province. Furthermore, PHC sectors had difficulties retaining existing LHWs due to low incomes and fewer opportunities for self-development. In-depth interviews discovered that, although numerous training opportunities have been provided for LHWs since 2009, the trainings did not achieve the expected outcome in LHW competency building, as LHWs actually did not have access to the trainings and the training design was unresponsive to the actual needs of LHWs. Both LHWs and leaders expressed an urgent need for effective training for LHWs based on systematic needs assessments and the use of qualified trainers and materials.

CONCLUSIONS

The shortage of qualified LHWs in PHC sectors became the bottleneck for BPHS delivery in Southwest China. Recent trainings for LHWs were less effective with regard to LHW competency building. A need-based professional training programme for LHWs by qualified trainers was expected by both LHWs and leaders in PHC sectors.

Factors influencing residents' decision to sign with family doctors under the new health care reform in China

BACKGROUND

As an important means through which to promote Chinese health care reform, the family doctor policy has attracted attention from various fields. This study aimed to explore the factors influencing residents' decision to sign with family doctors, with a view to informing the changes necessary to encourage additional residents to do so, thereby enhancing the efficacy of primary health care system reform.

METHODS

The residents of five communities in Xianning, Hubei Province, were selected, by convenience sampling, to participate in the study. We developed and administered a questionnaire to collect data, from which we obtained 725 valid response sets. Socio-demographic characteristics were summarized using descriptive statistics; and Pearson chi-squared test and binary logistic regression were performed to identify the factors influencing residents' decision to sign with family doctors.

RESULTS

We found that the factors influencing residents' decision to sign include their education level, medical insurance, chronic diseases, medical treatment habits, awareness of the family doctor policy, perception of the medical skills of family doctors, and attitudes towards family doctors' signing services (P < .05).

CONCLUSION

To encourage more residents to sign with family doctors, we recommend the implementation of the following: increasing publicity for the family doctor policy, promoting the reasonable distribution of high-quality resources, augmenting the standard of general medical education, and improving the skills and competencies of family doctors.

Problems and challenges: development of blood transfusion services in Mainland China within the context of health-care system reform

OBJECTIVE

To evaluate the development of blood transfusion services in Mainland China within the context of health-care system reform.

BACKGROUND

China launched a health-care reform program in 2009 to redistribute health-care resources, which are currently over-concentrated in well-developed cities. A geographically equitable blood transfusion service is key to achieving this goal.

METHODS

Based on the national survey of blood establishments in July 2015, total blood collection, whole-blood donations per 1000 population and the supply and demand relationship were analysed at the administrative region level. Areas at different developmental levels were compared in terms of total blood collection and human resources.

RESULTS

In 2014, Mainland China's 31 provinces showed wide variation, with total blood collection in blood facilities ranging from about 1000 units to over 600 000 units (each 200 mL), and the whole-blood donation rate per 1000 population, ranging from 1·48 to 17·09. 69% of the country's total collection, was concentrated in 29 provincial capitals, and 31% was in 311 non-capital cities. Of 97 personnel with doctorates, 74 worked in 32 provincial blood establishments, whereas the remaining 23 worked at the other 318 blood stations. In most provinces, per permanent resident donation was within 2-4 mL, and blood volume per inpatient was 10-35 mL regardless of the development of the transfusion service.

CONCLUSION

In 2014, China had an imbalanced development and insufficient access to blood transfusion services. This service must be redeployed at the national level to facilitate health-care reform in China.

[Human Resources for health policy mapping in Francophone African countries.]

OBJECTIVE

To identify all training, recruitment, deployment and retention programmes for healthcare human resources in five Francophone African countries in order to analyse progress in the authorities' efforts to resolve the problems of human resources for health.

METHODS

Analysis of policy processes was based on the University of Wisconsin logical framework approach to identify and describe programmes detailing missions and objectives, and outcome indicators. Data were derived from document analysis and interviews with key resource persons (N = 69).

RESULTS

Four main processes were identified: (1) training policies; (2) recruitment interventions; (3) strategies to improve governance by the creation of professional boards; (4) interventions on financial and non-financial incentive mechanisms. Two main groups of countries can be distinguished. One group presents a coherent succession of strategy integration (Burkina Faso, Mali) focusing on training policies to gradually move towards recruitment policies, deployment and incentive mechanisms. The other group presents a rupture of this political process with a return to training policies (Chad, Côte d'Ivoire) and recruitment and deployment policies (Côte d'Ivoire).

CONCLUSION

This study highlights the absence of structural reforms to improve health care performance to achieve Universal Health Coverage. A lack of policy impact evaluation and evidence-based data was also observed.

Offline Digital Education for Medical Students: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration

Background

Medical schools in low- and middle-income countries are facing a shortage of staff, limited infrastructure, and restricted access to fast and reliable internet. Offline digital education may be an alternative solution for these issues, allowing medical students to learn at their own time and pace, without the need for a network connection.

Objective

The primary objective of this systematic review was to assess the effectiveness of offline digital education compared with traditional learning or a different form of offline digital education such as CD-ROM or PowerPoint presentations in improving knowledge, skills, attitudes, and satisfaction of medical students. The secondary objective was to assess the cost-effectiveness of offline digital education, changes in its accessibility or availability, and its unintended/adverse effects on students.

Methods

We carried out a systematic review of the literature by following the Cochrane methodology. We searched seven major electronic databases from January 1990 to August 2017 for randomized controlled trials (RCTs) or cluster RCTs. Two authors independently screened studies, extracted data, and assessed the risk of bias. We assessed the quality of evidence using the Grading of Recommendations, Assessment, Development, and Evaluations criteria.

Results

We included 36 studies with 3325 medical students, of which 33 were RCTs and three were cluster RCTs. The interventions consisted of software programs, CD-ROMs, PowerPoint presentations, computer-based videos, and other computer-based interventions. The pooled estimate of 19 studies (1717 participants) showed no significant difference between offline digital education and traditional learning groups in terms of students’ postintervention knowledge scores (standardized mean difference=0.11, 95% CI –0.11 to 0.32; small effect size; low-quality evidence). Meta-analysis of four studies found that, compared with traditional learning, offline digital education improved medical students’ postintervention skills (standardized mean difference=1.05, 95% CI 0.15-1.95; large effect size; low-quality evidence). We are uncertain about the effects of offline digital education on students’ attitudes and satisfaction due to missing or incomplete outcome data. Only four studies estimated the costs of offline digital education, and none reported changes in accessibility or availability of such education or in the adverse effects. The risk of bias was predominantly high in more than half of the included studies. The overall quality of the evidence was low (for knowledge, skills, attitudes, and satisfaction) due to the study limitations and inconsistency across the studies.

Conclusions

Our findings suggest that offline digital education is as effective as traditional learning in terms of medical students’ knowledge and may be more effective than traditional learning in terms of medical students’ skills. However, there is a need to further investigate students’ attitudes and satisfaction with offline digital education as well as its cost-effectiveness, changes in its accessibility or availability, and any resulting unintended/adverse effects.

Health Services Management in Turkey: Failure or Success?

Background:

The unfair distribution and delivery of health-care resources have been recognized as a problem in the worldwide. In the past 18 years, Turkey has undergone rapid social, cultural, and economic changes. The lifestyle and dietary habits of its people have also been changing, and the rates of diabetes, obesity, cancer, and other chronic diseases have increased dramatically over the past two decades. The health transformation program (HTP) has improved the Turkish health-care system since 2003. The main goal of HTP was to progress government, to provide equality between citizens, to give satisfaction to users and providers, and to subsidise the health-care system in Turkey.

Aim:

The aim of this study is to assess health-care services and health care quality delivery in the Republic of Turkey with special emphasis on governmental hospitals, university hospitals, primary healthcare centers (PHC) and to make comparison with low-, medium- and high-income countries.

Methods:

This is a retrospective, descriptive study. The ministry of health Annual Reports, websites of the Central Intelligence Agency (CIA), The World Fact Book, organization for economic cooperation and development report, Compendium of Health Statistics, the Google engine, and PubMed were searched for information about Turkey's health-care system and its history. Papers and websites in English were evaluated. There was no restriction on types of articles and sources.

Results:

Turkey has made outstanding reforms in health status in the last two decades, especially after the implementation of the HTP. The doctor's perception has more influence regarding consultation length and visit than the patient’s. The results of consultations in volunteer practices in Istanbul showed that the mean and SD of the consultation length for the whole sample of 360 patients was 7.95 ± 4.38, (with range = 3–25 min). Consultation time has been affected by the patients’ diseases, genders that women got longer consultation time, medical practices at the urban or rural areas, and ages which older patients required longer consultation time. The current study revealed that increasing doctor's workload leads to decrease the length of consultations. Moreover, average life expectancy reached 75.3 for men and 80.7 for women in 2015. The infant mortality rate decreased to 10.7/1000 live births in 2015, down from 117.5 in 1980. The leading causes of death are diseases of the circulatory system followed by cancer.

Conclusions:

The Turkish health system and health-care delivery have been improved over the last decade. Still far from perfect, there is a particular planning to increase medical workforce in PHC including well-trained staffs for a specific area. An urgent need is to acquire more accurate and reliable data from hospital and PHC centers in Turkey. Additional some attempts should be made to assess quality of healthcare in relation to services and process.

[Midwives’ intention to leave primary level care services in Mali]

BACKGROUND

Mali is a country with a high rate of maternal and neonatal deaths and a low density of human resources for health. The health system faces understaffing and inequitable distribution of available resources. Health staff are reluctant to take positions and stay in first level care services. This study examines midwives and obstetric nurses' intention to leave their current positions in first level structures and management factors that influence this intention.

METHODS

A cross-sectional mixed method study was conducted with 220 midwives and obstetric nurses in 46 primary healthcare services of three health regions. Questionnaires and interview guide were used. Descriptive statistics and bi-varied analyses tested the links between managerial practices, demographic characteristics and intention to leave. A thematic analysis of the qualitative data examined the factors underlying the intention to leave.

RESULTS

Nearly half of midwives and obstetric nurses in primary healthcare services had the intention to leave their current positions. This intention to leave is more marked among midwives who have very little attraction for first-level service. Age, type of structure and area of assignment are strongly associated with the intention to leave. Managerial practices that differ according to locations and type of structures seem to influence the intention to leave.

CONCLUSION

There is a high intention to leave their position among midwives and obstetric nurses in first level services. Managerial practices seem to have more influences on the intention to leave in rural areas and among obstetric nurses.

Job preferences for healthcare administration students in China: A discrete choice experiment

Background

There is a deficiency of healthcare administrators in China as compared with other countries; furthermore, the distribution is unequal. To inform an effective policy intervention, it is crucial to understand healthcare administration students’ career decision-making. This study aims to investigate the undergraduate students’ stated preferences when choosing a job.

Methods

A discrete choice experiment (DCE) was conducted among a population-based multistage sample of 668 final year undergraduate healthcare administration students during April to June 2017 in eight universities of China to elicit their job preferences. Attributes include location, monthly income, bianzhi (which refers to the established posts and can be loosely regarded as state administrative staffing), training and career development opportunity, working environment and workload. Conditional and mixed logit models were used to analyze the relative importance of job attributes.

Results

All six attributes were statistically significant with the expected sign and demonstrated the existence of preference heterogeneity. Monthly income, workload and working environment were of most concern to healthcare administration students when deciding their future. Among the presented attributes bianzhi was of the least concern. Sub-group analysis showed that students who have an urban background and/or with higher annual family incomes were willing to pay more for working in the city. In addition, students from western and middle universities valued bianzhi higher than students from eastern universities.

Conclusions

This is the first study focusing on the career decision-making of Chinese healthcare administration students at a critical career decision-making point. Both monetary and non-monetary interventions could be considered by policy-makers to attract students to work in health institutions, especially in rural and remote health institutions in China. There exists preference heterogeneity on healthcare administration students’ job preferences, which should also be taken into account in developing more effective policy incentive packages.

Digital depression screening in HIV primary care in South Africa: mood in retroviral + application monitoring [MIR + IAM]

BACKGROUND

Integrating mental health care into HIV services is critical to addressing the high unmet treatment needs for people living with HIV and comorbid major depressive disorder. Introducing routine mental health screening at the primary health care level is a much needed diagonal approach to enhancing HIV care. In low-resource settings with a shortage of mental health care providers, eMental Health may provide a novel opportunity to attenuate this treatment gap and strengthen the health system.

OBJECTIVE

To conduct formative health systems research on the implementation of routine depression screening using a digital tool - Mood in Retroviral Positive Individuals Application Monitoring (MIR  +  IAM) - in an HIV primary care setting in South Africa.

METHODS

A Theory of Change (ToC) approach was utilised through individual and group session interviews to design an intervention that is embedded in the local context. Ten experts and local stakeholders were selected from the UK and South Africa. Data were analysed thematically using Atlas.ti to identify interventions, assumptions, barriers and facilitators of implementation.

FINDINGS

The participants considered digital depression screening in HIV care services relevant for the improvement of mental health in this population. The six main themes identified from the ToC process were: (1) user experience including acceptability by patients, issues of patient privacy and digital literacy, and the need for a patient-centred tool; (2) benefits of the digital tool for data collection and health promotion; (3) availability of treatment after diagnosis; (4) human and physical resource capacity of primary health care; (5) training for lay health care workers; and (6) demonstration of the intervention's usefulness to generate interest from decision-makers.

CONCLUSION

Digital depression screening coupled with routine mental health data collection and analysis in HIV care is an applicable service that could improve the mental and physical health outcomes of this population. Careful consideration of the local health system capacity, including both workers and patients, is required. Future research to refine this intervention should focus on service users, government stakeholders and funders.