Motivating provision of high quality care: it is not all about the money

How do pro-social tendencies and provider biases affect service delivery? Evidence from the rollout of self-injection of DMPA-SC in Nigeria

BACKGROUND

Inconsistent provision of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) for self-injection (SI) undermines efforts to improve women's reproductive health agency and access to self-care. In Nigeria, providers feel pro-social responsibility as frontline health workers to support their clients' wellbeing. However, their pronatalist beliefs censure premarital sexual activity and inhibit access to contraceptives for young, unmarried women. How pro-social tendencies and provider biases interact to affect service delivery is a critical but underexplored question.

METHODS

We conducted a mixed-methods study comparing stated pro-social tendencies and intentions to dispense DMPA-SC for SI (N = 81 in-depth interviews (IDIs)) with actual dispensing behavior during mystery client (MC) visits (N = 162 post-interaction surveys) across private and public facilities in Lagos, Enugu and Plateau. Qualitative analysis of providers' pro-social tendencies, biases, and reasons for not offering DMPA-SC for SI complemented quantitative analysis exploring the associations between pro-social tendencies and dispensing behavior.

RESULTS

Providers showed substantial levels of both pro-social tendencies and bias against young, unmarried women. High levels of stated intentions to dispense in IDIs (91% to older, married women vs 78% to young, unmarried women) did not translate to actual willingness to dispense in MC visits (30% to older, married women vs 27% to young, unmarried women). Young, unmarried actors were twice as likely to perceive differential treatment from providers (33%) relative to older, married women actors (17%). From IDIs, providers expressed biases about the appropriateness of family planning and SI specifically based on a client's age, marital status, parity, and covert use. In some cases, pro-social tendencies reinforced bias when providers sought to uphold social norms as a gatekeeper; in other cases, pro-social tendencies on self-defined client needs helped overcome bias. Providers described other factors that deterred them from dispensing DMPA-SC for SI, including elements of self-care that posed risks to their practice or business.

CONCLUSIONS

Provider biases may limit provision of DMPA-SC for SI, which could affect contraceptive equity and women's control over their own fertility, especially for younger, unmarried women. Targeted interventions that effectively address provider biases against young, unmarried women, potentially leveraging providers' underlying pro-social tendencies, may help ensure equity in client access to contraceptive self-care.

Effect of Performance-Based Nonfinancial Incentives on Data Quality in Individual Medical Records of Institutional Births: Quasi-Experimental Study

BACKGROUND

Despite the potential of routine health information systems in tackling persistent maternal deaths stemming from poor service quality at health facilities during and around childbirth, research has demonstrated their suboptimal performance, evident from the incomplete and inaccurate data unfit for practical use. There is a consensus that nonfinancial incentives can enhance health care providers' commitment toward achieving the desired health care quality. However, there is limited evidence regarding the effectiveness of nonfinancial incentives in improving the data quality of institutional birth services in Ethiopia.

OBJECTIVE

This study aimed to evaluate the effect of performance-based nonfinancial incentives on the completeness and consistency of data in the individual medical records of women who availed institutional birth services in northwest Ethiopia.

METHODS

We used a quasi-experimental design with a comparator group in the pre-post period, using a sample of 1969 women's medical records. The study was conducted in the "Wegera" and "Tach-armacheho" districts, which served as the intervention and comparator districts, respectively. The intervention comprised a multicomponent nonfinancial incentive, including smartphones, flash disks, power banks, certificates, and scholarships. Personal records of women who gave birth within 6 months before (April to September 2020) and after (February to July 2021) the intervention were included. Three distinct women's birth records were examined: the integrated card, integrated individual folder, and delivery register. The completeness of the data was determined by examining the presence of data elements, whereas the consistency check involved evaluating the agreement of data elements among women's birth records. The average treatment effect on the treated (ATET), with 95% CIs, was computed using a difference-in-differences model.

RESULTS

In the intervention district, data completeness in women's personal records was nearly 4 times higher (ATET 3.8, 95% CI 2.2-5.5; P=.02), and consistency was approximately 12 times more likely (ATET 11.6, 95% CI 4.18-19; P=.03) than in the comparator district.

CONCLUSIONS

This study indicates that performance-based nonfinancial incentives enhance data quality in the personal records of institutional births. Health care planners can adapt these incentives to improve the data quality of comparable medical records, particularly pregnancy-related data within health care facilities. Future research is needed to assess the effectiveness of nonfinancial incentives across diverse contexts to support successful scale-up.

Association between antenatal care facility readiness and provision of care at the client level and facility level in five low- and middle-income countries

BACKGROUND

Despite growing interest in monitoring improvements in quality of care, data on service quality in low-income and middle-income countries (LMICs) is limited. While health systems researchers have hypothesized the relationship between facility readiness and provision of care, there have been few attempts to quantify this relationship in LMICs. This study assesses the association between facility readiness and provision of care for antenatal care at the client level and facility level.

METHODS

To assess the association between provision of care and various facility readiness indices for antenatal care, we used multilevel, multivariable random-effects linear regression models. We tested an inflection point on readiness scores by fitting linear spline models. To compare the coefficients between models, we used a bootstrapping approach and calculated the mean difference between all pairwise comparisons. Analyses were conducted at client and facility levels.

RESULTS

Our results showed a small, but significant association between facility readiness and provision of care across countries and most index constructions. The association was most evident in the client-level analyses that had a larger sample size and were adjusted for factors at the facility, health worker, and individual levels. In addition, spline models at a facility readiness score of 50 better fit the data, indicating a plausible threshold effect.

CONCLUSIONS

The results of this study suggest that facility readiness is not a proxy for provision of care, but that there is an important association between facility readiness and provision of care. Data on facility readiness is necessary for understanding the foundations of health systems particularly in countries with the lowest levels of service quality. However, a comprehensive view of quality of care should include both facility readiness and provision of care measures.

Mapping GPs' motivation — it's not all about the money: a nationwide cross-sectional survey study from Denmark

BACKGROUND

Understanding physicians' motivation may be essential for policymakers if they are to design policies that cater to physicians' wellbeing, job retention, and quality of care. However, physicians' motivation remains an understudied area.

AIM

To map GPs' work motivation.

DESIGN AND SETTING

A cross-sectional analysis using registry and survey data from Denmark.

METHOD

Survey data were used to measure four types of motivation: extrinsic motivation, intrinsic motivation, user orientation, and public service motivation. These were combined with register data on the characteristics of the GP, practice, and area. Using latent profile analysis, the heterogeneity in GPs' motivation was explored; the associations between GPs' motivation and the GP, practice, and area characteristics were estimated using linear regression analyses.

RESULTS

There was substantial heterogeneity in GPs' motivations. Five classes of GPs were identified with different work motivations: class 1 'it is less about the money' - probability of class membership 53.2%; class 2 'it is about everything' - 26.5%; class 3 'it is about helping others' - 8.6%; class 4 'it is about the work' - 8.2%; and class 5 'it is about the money and the patient' - 3.5%. Linear regression analyses showed that motivation was associated with GP, practice, and area characteristics to a limited extent only.

CONCLUSION

GPs differ in their work motivations. The finding that, for many GPs, 'it is not all about the money' indicated that their different motivations should be considered when designing new policies and organisational structures to retain the workforce and ensure a high quality of care.

COVID-19 crisis management of German ICU clinicians in leadership - a metaphor analysis

The COVID-19 pandemic coincided with an already long-standing crisis in health systems around the world characterized by economic pressure and increasing staff shortage. "Crisis" became a global metaphor to convey collective experiences of the COVID-19 threat. Little is known on how crisis metaphors influence thought and speech on crisis management and the challenging staff situation of intensive care unit (ICU) clinicians in leadership positions and how they act. Therefore, we were interested in (1) which metaphorical concepts ICU clinicians in leadership use to express experiences and strategies in dealing with coinciding crises, (2) how these change over time, and (3) how metaphors in speech reveal self-images of crisis management. We conducted a systematic metaphor analysis focusing on data from three participants of a qualitative interview study with twenty-four healthcare professionals in ICUs in Germany. The participants were interviewed at two time points between April 2020 and March 2021. We identified and reconstructed metaphorical concepts of three interviewees (ICU clinicians in leadership) with regard to the pandemic management, and developed a typology based on the dimensions of mood, modus operandi, location, and scope. The typology consists of eight self-images (protagonists) for the crisis management of ICU clinicians in leadership, such as the figure of the soldier ("to unite everyone behind this flag"), the distributor ("sometimes it is a crazy patchwork [wahnsinniges Gestückel]") or the critic ("we are the fool for everything"). They embody different qualities of a leader and refer to intra- and inter-role conflicts within multiple crisis conditions. Metaphor analysis reveals different self-images of ICU leadership clinicians in relation to crisis management. This illustrates that thinking and perceptions of crisis management may strongly differ between and within leaders and may change over the course of crises. Our findings highlight the need both to improve knowledge on challenges associated with leadership in crises and preparedness, and to support clinicians in their leadership by recognizing and addressing differences and changes in leaders' self-image.

Organizational attributes that contribute to the learning & improvement capabilities of healthcare organizations: a scoping review

BACKGROUND

This study aims to explore and identify the organizational attributes that contribute to learning and improvement capabilities (L&IC) in healthcare organizations. The authors define learning as a structured update of system properties based on new information, and improvement as a closer correspondence between actual and desired standards. They highlight the importance of learning and improvement capabilities in maintaining high-quality care, and emphasize the need for empirical research on organizational attributes that contribute to these capabilities. The study has implications for healthcare organizations, professionals, and regulators in understanding how to assess and enhance learning and improvement capabilities.

METHODS

A systematic search of peer-reviewed articles published between January 2010 and April 2020 was carried out in the PubMed, Embase, CINAHL, and APA PsycINFO databases. Two reviewers independently screened the titles and abstracts and conducted a full-text review of potentially relevant articles, eventually adding five more studies identified through reference scanning. Finally, a total of 32 articles were included in this review. We extracted the data about organizational attributes that contribute to learning and improvement, categorized them and grouped the findings step-by-step into higher, more general-level categories using an interpretive approach until categories emerged that were sufficiently different from each other while also being internally consistent. This synthesis has been discussed by the authors.

RESULTS

We identified five attributes that contribute to the L&IC of healthcare organizations: perceived leadership commitment, open culture, room for team development, initiating and monitoring change, and strategic client focus, each consisting of multiple facilitating aspects. We also found some hindering aspects.

CONCLUSIONS

We have identified five attributes that contribute to L&IC, mainly related to organizational software elements. Only a few are identified as organizational hardware elements. The use of qualitative methods seems most appropriate to understand or assess these organizational attributes. We feel it is also important for healthcare organisations to look more closely at how clients can be involved in L&IC.

TRIAL REGISTRATION

Not applicable.

Mobilizing registry data for quality improvement: A convergent mixed-methods analysis and application to spinal cord injury

Introduction

The rising prevalence of complex chronic conditions and growing intricacies of healthcare systems emphasizes the need for interdisciplinary partnerships to advance coordination and quality of rehabilitation care. Registry databases are increasingly used for clinical monitoring and quality improvement (QI) of health system change. Currently, it is unclear how interdisciplinary partnerships can best mobilize registry data to support QI across care settings for complex chronic conditions.

Purpose

We employed spinal cord injury (SCI) as a case study of a highly disruptive and debilitating complex chronic condition, with existing registry data that is underutilized for QI. We aimed to compare and converge evidence from previous reports and multi-disciplinary experts in order to outline the major elements of a strategy to effectively mobilize registry data for QI of care for complex chronic conditions.

Methods

This study used a convergent parallel-database variant mixed design, whereby findings from a systematic review and a qualitative exploration were analyzed independently and then simultaneously. The scoping review used a three-stage process to review 282 records, which resulted in 28 articles reviewed for analysis. Concurrent interviews were conducted with multidisciplinary-stakeholders, including leadership from condition-specific national registries, members of national SCI communities, leadership from SCI community organizations, and a person with lived experience of SCI. Descriptive analysis was used for the scoping review and qualitative description for stakeholder interviews.

Results

There were 28 articles included in the scoping review and 11 multidisciplinary-stakeholders in the semi-structured interviews. The integration of the results allowed the identification of three key learnings to enhance the successful design and use of registry data to inform the planning and development of a QI initiative: enhance utility and reliability of registry data; form a steering committee lead by clinical champions; and design effective, feasible, and sustainable QI initiatives.

Conclusion

This study highlights the importance of interdisciplinary partnerships to support QI of care for persons with complex conditions. It provides practical strategies to determine mutual priorities that promote implementation and sustained use of registry data to inform QI. Learnings from this work could enhance interdisciplinary collaboration to support QI of care for rehabilitation for persons with complex chronic conditions.

Do breaks from surgery improve the performance of orthopaedic surgeons?

This paper explores whether breaks from surgical practice impact surgeons' performance. Using a large panel of orthopaedic surgeons in England, I estimate the effect of surgeons' breaks, measured by the number of days since their last surgery, on the health outcomes of emergency patients admitted after a hip fracture. To identify a causal effect, I implement a surgeon fixed effects model and exploit the quasi-exogenous variation in breaks from unanticipated emergency hip fracture admissions. Results show that short breaks of four to six days reduce 30-day mortality rates by around six percent relative to no breaks. Notably, short breaks also affect the type of surgery carried out, holding patient characteristics fixed. Overall, these findings show that the organisation of surgeons' activity is a possible determinant of the quality of care provided.

Availability and Accessibility of Orphan Medicinal Products to Patients in Slovakia in the Years 2010-2019

Objective: Information about the access of Slovak patients to orphan medicinal products (OMPs) in the literature is rather scarce. The main aim of the study was to analyze the accessibility and availability of OMPs to Slovak patients in the years 2010-2019. Methods: The analyzed OMPs were strictly defined according to the European definition. The date of marketing authorization together with its first appearance in the positive drug list was used to count the time to reach the national market. The data from the National Health Information Centre, the Ministry of Health, and health insurance companies were used as data sources of drug usage, expenditure, consumption, reimbursement of OMPs, as well as the total number of treated patients. Results: Out of the 167 OMPs on the European market, we identified 52% (87) OMPs which had any kind of costs recorded in Slovakia. Out of them, 62% (54) OMPs were directly present on the positive drug list. The remaining 33 OMPs were available on exception. The trend in accessibility and availability of OMPs in Slovakia between the years 2010 and 2019 was decreasing (57% OMPs in 2010 vs. 47% OMPs in 2019). The average time for an orphan medicinal product to reach the Slovak market was almost 4 years, 43.5 months [6-202 months]. Together, 10.4% (8 815 patients) out of the theoretical patients' estimation according to the prevalence in the orphan designation were treated with OMPs available in Slovakia. Conclusion: Presented data clearly show insufficient accessibility and availability of OMPs in Slovakia. Importance of clearly defined criteria for OMPs supporting patients and healthcare professionals' involvement in the final decision together with other measures such as social impact, improvement of patients' quality of life, society wide meaning, or no alternative treatment in the final decision is crucial for transparent and sustainable access to OMPs and innovative treatments in Slovakia.

Assessing the feasibility and acceptability of a financial versus behavioural incentive-based intervention for community health workers in rural Indonesia

BACKGROUND

The World Health Organization recommends that community health workers (CHWs) receive a mix of financial and non-financial incentives, yet notes that there is limited evidence to support the use of one type of incentive (i.e. financial or non-financial) over another. In preparation for a larger scale trial, we investigated the acceptability and feasibility of two different forms of incentives for CHWs in Malang District, Indonesia.

METHODS

CHWs working on a cardiovascular disease (CVD) risk screening and management programme in two villages were assigned to receive either a financial or non-financial incentive for 6 months. In the financial incentives village, CHWs (n = 20) received 16,000 IDR (USD 1.1) per patient followed up or 500,000 IDR (USD 34.1) if they followed up 100% of their assigned high-risk CVD patients each month. In the non-financial incentive village, CHWs (n = 20) were eligible to receive a Quality Care Certificate for following up the highest number of high-risk CVD patients each month, awarded in a public ceremony. At the end of the 6-month intervention period, focus group discussions were conducted with CHWs and semi-structured interviews with programme administrators to investigate acceptability, facilitators and barriers to implementation and feasibility of the incentive models. Data on monthly CHW follow-up activity were analysed using descriptive statistics to assess the preliminary impact of each incentive on service delivery outcomes, and CHW motivation levels were assessed pre- and post-implementation.

RESULTS

Factors beyond the control of the study significantly interrupted the implementation of the financial incentive, particularly the threat of violence towards CHWs due to village government elections. Despite CHWs reporting that both the financial and non-financial incentives were acceptable, programme administrators questioned the sustainability of the non-financial incentive and reported CHWs were ambivalent towards them. CHW service delivery outcomes increased 17% for CHWs eligible for the non-financial incentive and 21% for CHWs eligible for the financial incentive. There was a statistically significant increase (p < 0.0001) in motivation scores for the performance domain in both villages.

CONCLUSION

It was feasible to deliver both a performance-based financial and non-financial incentive to CHWs in Malang District, Indonesia, and both incentive types were acceptable to CHWs and programme administrators. Evidence of preliminary effectiveness also suggests that both the financial and non-financial incentives were associated with improved motivation and service delivery outcomes. These findings will inform the next phase of incentive design, in which incentive feasibility and preliminary effectiveness will need to be considered alongside their longer-term sustainability within the health system.

Utilizing Technology for Dermatology Care in Tajikistan: A Health Systems Perspective

In Tajikistan, dermatologic services are available across the country. Yet, the most experienced dermatologists work at the National Republic Center for Dermatology and Venereology (NRCDV). Patients from across the country bypass local dermatologists and self-refer to NRCDV. Furthermore, no formal mechanisms exist for dermatologists in different cities to consult with experts at NRCDV. The authors designed a teledermatology program linking dermatologists across Tajikistan to NRCDV. They used the World Health Organization health systems framework to plan this program and define objectives. To date, 228 teledermatology consultations have taken place. The authors find that good governance is key to program implementation.

Meaning of Success: perception of medical students, and faculty-A Qualitative Study from a medical school in Mauritius

Background

The objective of this study was to find what undergraduate medical students and teaching faculty perceive success to be.

Methods

A descriptive phenomenological qualitative study was designed and conducted on faculty and medical students in Sir Seewoosagur Ramgoolam Medical College, Mauritius. NVivo 12 (Windows) Plus software was implemented for data analysis and thematic analysis was performed.

Results

The codes/nodes namely being: Satisfaction, Accomplishment, Actions, Motivations, Extrinsic Factors and Intrinsic Factors were identified in the transcribed data. Satisfaction was described as the positive emotions and notions intimately related as well as synonymously associated with success. Accomplishment as the attainment and fulfilment of any physical, mental, emotional, social, occupational, personal goal or desire by an individual. Actions was the arsenal of physical processes, acts of planning, goal setting or forethinking exercised by the individual. Motivations was the drive to attain the preset goal or notion be it positive or negative. This applies to factors that enable a subject to strive forwards. Extrinsic Factors were the external determinants and definition of success perceived by the subject. Intrinsic Factors were the subject's internal organic, comprehension and definition of success. The themes generated were: Products of Success, Mechanisms of Success and Concepts of success.

Conclusion

A tangible demarcation is noticeable between the preconceived general impression of success and the vast multifactorial cohort of intrinsic and extrinsic factors coupled to the highly emotional aspects which were brought forth.

Mentoring the working nurse: a scoping review

BACKGROUND

Mentoring programs for nurses already in the health workforce are growing in importance. Yet, the settings, goals, scale, and key features of these programs are not widely known.

OBJECTIVE

To identify and synthesize research on in-service nurse mentoring programs.

METHODS

We reviewed nurse mentoring research from six databases. Studies either referred explicitly to in-service nurse mentoring programs, were reviews of such programs, or concerned nurse training/education in which mentoring was an essential component.

RESULTS

We included 69 articles from 11 countries, published from 1995 to 2019. Most articles were from high-income countries (n = 46) and in rural areas (n = 22). Programs were developed to strengthen clinical care (particularly maternal and neonatal care), promote evidence-based practice, promote retention, support new graduate nurses, and develop nurse leaders. Of the articles with sufficient data, they typically described small programs implemented in one facility (n = 23), with up to ten mentors (n = 13), with less than 50 mentees (n = 25), meeting at least once a month (n = 27), and lasting at least a year (n = 24). While over half of the studies (n = 36) described programs focused almost exclusively on clinical skills acquisition, many (n = 33) specified non-clinical professional development activities. Reflective practice featured to a varying extent in many articles (n = 29). Very few (n = 6) explicitly identified the theoretical basis of their programs.

CONCLUSIONS

Although the literature about in-service nurse mentoring comes mostly from small programs in high-income countries, the largest nurse mentoring programs in the world are in low- and middle-income countries. Much can be learned from studying these programs in greater detail. Future research should analyze key features of programs to make models of mentoring more transparent and translatable. If carefully designed and flexibly implemented, in-service nurse mentoring represents an exciting avenue for enhancing the role of nurses and midwives in people-centered health system strengthening. The contents in this article are those of the authors and do not necessarily reflect the view of the U.S. President's Emergency Plan for AIDS Relief, the U.S. Agency for International Development or the U.S. Government.