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Desmond N, Henrion MYR, Gondwe M, O’Byrne T, Iroh Tam PY, Nyirenda D, Pollock L, Majamanda MD, Makwero M, Geldof M, Dube Q, Phiri C, Banda C, Kachala R, Heyderman PRS, Masesa C, Lufesi N, Lalloo DG. Improving care pathways for children with severe illness through implementation of the ASPIRE mHealth primary ETAT package in Malawi. PLOS Glob Public Health 2024; 4:e0002786. [PMID: 38683833 PMCID: PMC11057765 DOI: 10.1371/journal.pgph.0002786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 03/27/2024] [Indexed: 05/02/2024]
Abstract
Providing emergency care in low resource settings relies on delivery by lower cadres of health workers (LCHW). We describe the development, implementation and mixed methods evaluation of a mobile health (mHealth) triage algorithm based on the WHO Emergency, Triage, Assessment, and Treatment (ETAT) for primary-level care. We conducted an observational study design of implementation research. Key stakeholders were engaged throughout implementation. Clinicians and LCHW at eight primary health centres in Blantyre district were trained to use an mHealth algorithm for triage. An mHealth patient surveillance system monitored patients from presentation through referral to tertiary and final outcome. A total of 209,174 children were recorded by ETAT between April 2017 and September 2018, and 155,931 had both recorded mHealth and clinician triage outcome data. Concordance between mHealth triage by lower cadres of HCW and clinician assessment was 81·6% (95% CI [81·4, 81·8]) over all outcomes (kappa: 0·535 (95% CI [0·530, 0·539]). Concordance for mHealth emergency triage was 0.31 with kappa 0.42. The most common mHealth recorded emergency sign was breathing difficulty (74·1% 95% CI [70·1, 77·9]) and priority sign was raised temperature (76·2% (95% CI [75·9, 76·6]). A total of 1,644 referrals out of 3,004 (54·7%) successfully reached the tertiary site. Both providers and carers expressed high levels of satisfaction with the mHealth ETAT pathway. An mHealth triage algorithm can be used by LCHWs with moderate concordance with clinician triage. Implementation of ETAT through an mHealth algorithm documented successful referrals from primary to tertiary, but half of referred patients did not reach the tertiary site. Potential harms of such systems, such as cases requiring referral being missed during triage, require further evaluation. The ASPIRE mHealth primary ETAT approach can be used to prioritise acute illness and support future resource planning within both district and national health system.
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Affiliation(s)
- Nicola Desmond
- Social Sciences Research Group, and Paediatrics and Child Health Research Group, Malawi Liverpool Wellcome Trust, Blantyre, Malawi
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Marc Y. R. Henrion
- Social Sciences Research Group, and Paediatrics and Child Health Research Group, Malawi Liverpool Wellcome Trust, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Mtisunge Gondwe
- Social Sciences Research Group, and Paediatrics and Child Health Research Group, Malawi Liverpool Wellcome Trust, Blantyre, Malawi
| | - Thomasena O’Byrne
- Social Sciences Research Group, and Paediatrics and Child Health Research Group, Malawi Liverpool Wellcome Trust, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Pui-Ying Iroh Tam
- Social Sciences Research Group, and Paediatrics and Child Health Research Group, Malawi Liverpool Wellcome Trust, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Deborah Nyirenda
- Social Sciences Research Group, and Paediatrics and Child Health Research Group, Malawi Liverpool Wellcome Trust, Blantyre, Malawi
| | - Louisa Pollock
- Social Sciences Research Group, and Paediatrics and Child Health Research Group, Malawi Liverpool Wellcome Trust, Blantyre, Malawi
| | - Maureen Daisy Majamanda
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Martha Makwero
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- World Health Organization, Geneva, Switzerland
| | | | - Queen Dube
- Ministry of Health, Lilongwe, Malawi
- Department of Paediatrics and Child Health, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Chimwemwe Phiri
- Department of Anthropology, University of Durham, Durham, United Kingdom
| | - Chimwemwe Banda
- International Food Policy Research Institute, Lilongwe, Malawi
| | | | - Prof Robert S. Heyderman
- Research Department of Infection, Division of Infection and Immunity, University College London, United Kingdom
| | - Clemens Masesa
- Social Sciences Research Group, and Paediatrics and Child Health Research Group, Malawi Liverpool Wellcome Trust, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | | | - David G. Lalloo
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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Smith JL, Ritchie MJ, Kim B, Miller CJ, Chinman MJ, Kelly PA, Landes SJ, Kirchner JE. Getting to Fidelity: Consensus Development Process to Identify Core Activities of Implementation Facilitation. Glob Implement Res Appl 2024; 2024:10.1007/s43477-024-00119-5. [PMID: 38765294 PMCID: PMC11100021 DOI: 10.1007/s43477-024-00119-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 03/16/2024] [Indexed: 05/22/2024]
Abstract
Transferring successful implementation strategies from research to practice requires approaches for assessing fidelity to the strategy's core components. Implementation facilitation (IF) is a strategy involving an interactive process of problem-solving, enabling, and supporting individuals in efforts to implement clinical innovations that occurs in the context of a recognized need for improvement and supportive interpersonal relationships. Because IF is a dynamic strategy involving numerous activities, our objective was to conduct a rigorous consensus development process to identify core activities for monitoring fidelity to IF when applied in clinical settings. We first conducted a scoping literature review to identify the range of activities used when IF has been applied in clinical settings, searching multiple citation databases for English-language articles including "facilitation" or other commonly-used terms for the strategy published from 1996-2015. Through multi-stage screening, 135 articles (from 94 studies) were identified for data extraction on IF activities, frequency with which IF activities were identified as 'core' by study authors, and study outcomes. From the literature review, we identified 32 distinct IF activities and developed definitions/examples for each. Next, we conducted a 3-stage, modified-Delphi expert panel consensus development process to identify core IF activities across three implementation phases (i.e., Pre-Implementation, Implementation, Sustainment). The expert panel identified 8 core activities for the Pre-Implementation Phase, 8 core activities for the Implementation Phase, and 4 core activities for the Sustainment Phase. This work provides an important foundation for developing measures/tools to assess use of core IF activities to ensure the strategy is delivered with fidelity.
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Affiliation(s)
- Jeffrey L. Smith
- VA Behavioral Health Quality Enhancement Research Initiative (QUERI) & HSR&D Center for Mental Healthcare & Outcomes Research (CeMHOR), Central Arkansas Veterans Healthcare System, 900 S. Shackelford Road, Fifth Floor, Little Rock, AR 72211, USA
- Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 W. Markham Street, #755, Little Rock, AR 72205, USA
| | - Mona J. Ritchie
- VA Behavioral Health Quality Enhancement Research Initiative (QUERI) & HSR&D Center for Mental Healthcare & Outcomes Research (CeMHOR), Central Arkansas Veterans Healthcare System, 900 S. Shackelford Road, Fifth Floor, Little Rock, AR 72211, USA
- Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 W. Markham Street, #755, Little Rock, AR 72205, USA
| | - Bo Kim
- VA Behavioral Health QUERI & HSR&D Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA 02130, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA 02115, USA
| | - Christopher J. Miller
- VA Behavioral Health QUERI & HSR&D Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA 02130, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA 02115, USA
| | - Matthew J. Chinman
- VA Pittsburgh Healthcare System, Research Office Building (151R), University Drive C, Pittsburgh, PA 15240, USA
| | - P. Adam Kelly
- Southeast Louisiana Veterans Healthcare System, 2400 Canal Street (11F), New Orleans, LA 70119, USA
| | - Sara J. Landes
- VA Behavioral Health Quality Enhancement Research Initiative (QUERI) & HSR&D Center for Mental Healthcare & Outcomes Research (CeMHOR), Central Arkansas Veterans Healthcare System, 900 S. Shackelford Road, Fifth Floor, Little Rock, AR 72211, USA
- Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 W. Markham Street, #755, Little Rock, AR 72205, USA
| | - JoAnn E. Kirchner
- VA Behavioral Health Quality Enhancement Research Initiative (QUERI) & HSR&D Center for Mental Healthcare & Outcomes Research (CeMHOR), Central Arkansas Veterans Healthcare System, 900 S. Shackelford Road, Fifth Floor, Little Rock, AR 72211, USA
- Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 W. Markham Street, #755, Little Rock, AR 72205, USA
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Agulnik A, Boykin D, O'Malley DM, Price J, Yang M, McKone M, Curran G, Ritchie MJ. Virtual facilitation best practices and research priorities: a scoping review. Implement Sci Commun 2024; 5:16. [PMID: 38365878 PMCID: PMC10873989 DOI: 10.1186/s43058-024-00551-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 01/24/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Facilitation is an implementation strategy that supports the uptake of evidence-based practices. Recently, use of virtual facilitation (VF), or the application of facilitation using primarily video-based conferencing technologies, has become more common, especially since the COVID-19 pandemic. Thorough assessment of the literature on VF, however, is lacking. This scoping review aimed to identify and describe conceptual definitions of VF, evaluate the consistency of terminology, and recommend "best" practices for its use as an implementation strategy. METHODS We conducted a scoping review to identify literature on VF following the PRISMA-ScR guidance. A search of PubMed, Embase, Web of Science, and CINAHL databases was conducted in June 2022 for English language articles published from January 2012 through May 2022 and repeated in May 2023 for articles published from January 2012 through April 2023. Identified articles, including studies and conference abstracts describing VF, were uploaded into Covidence and screened independently by two reviewers. Data extraction was done by two reviewers in Microsoft Excel; additionally, studies were evaluated based on the Proctor et al. (2013) reporting guidelines for specifying details of implementation strategies. RESULTS The search strategy identified 19 articles. After abstract and full-text screening, eight studies described by 10 articles/abstracts were included in analysis. Best practices summarized across studies included (1) stakeholder engagement, (2) understanding the recipient's organization, (3) facilitator training, (4) piloting, (5) evaluating facilitation, (6) use of group facilitation to encourage learning, and (7) integrating novel tools for virtual interaction. Three papers reported all or nearly all components of the Proctor et al. reporting guidelines; justification for use of VF was the most frequently omitted. CONCLUSIONS This scoping review evaluated available literature on use of VF as a primary implementation strategy and identified significant variability on how VF is reported, including inconsistent terminology, lack of details about how and why it was conducted, and limited adherence to published reporting guidelines. These inconsistencies impact generalizability of these methods by preventing replicability and full understanding of this emerging methodology. More work is needed to develop and evaluate best practices for effective VF to promote uptake of evidence-based interventions. TRIAL REGISTRATION N/A.
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Affiliation(s)
- Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA.
- Division of Critical Care, St. Jude Children's Research Hospital, Memphis, TN, USA.
| | - Derrecka Boykin
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Denalee M O'Malley
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, Research DivisionNew Brunswick, NJ, USA
| | - Julia Price
- Center for Healthcare Delivery Science, Nemours Children's Health , Wilmington, DE, USA
- Department of Pediatrics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, USA
| | - Mia Yang
- Department of Internal Medicine, Section of Gerontology and Geriatric Medicine and the Sticht Center for Healthy Aging and Alzheimer's Prevention, Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist, Winston Salem, NC, USA
| | - Mark McKone
- Coy C. Carpenter Library, Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | - Geoffrey Curran
- Department of Pharmacy Practice, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Mona J Ritchie
- VA Behavioral Health Quality Enhancement Research Initiative (QUERI), Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA
- Department of Psychiatry and Behavioral Sciences, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Meaney PA, Hokororo A, Ndosi H, Dahlen A, Jacob T, Mwanga JR, Kalabamu FS, Joyce CL, Mediratta R, Rozenfeld B, Berg M, Smith ZH, Chami N, Mkopi N, Mwanga C, Diocles E, Agweyu A. Implementing adaptive e-learning for newborn care in Tanzania: an observational study of provider engagement and knowledge gains. BMJ Open 2024; 14:e077834. [PMID: 38309746 PMCID: PMC10840034 DOI: 10.1136/bmjopen-2023-077834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 01/09/2024] [Indexed: 02/05/2024] Open
Abstract
INTRODUCTION To improve healthcare provider knowledge of Tanzanian newborn care guidelines, we developed adaptive Essential and Sick Newborn Care (aESNC), an adaptive e-learning environment. The objectives of this study were to (1) assess implementation success with use of in-person support and nudging strategy and (2) describe baseline provider knowledge and metacognition. METHODS 6-month observational study at one zonal hospital and three health centres in Mwanza, Tanzania. To assess implementation success, we used the Reach, Efficacy, Adoption, Implementation and Maintenance framework and to describe baseline provider knowledge and metacognition we used Howell's conscious-competence model. Additionally, we explored provider characteristics associated with initial learning completion or persistent activity. RESULTS aESNC reached 85% (195/231) of providers: 75 medical, 53 nursing and 21 clinical officers; 110 (56%) were at the zonal hospital and 85 (44%) at health centres. Median clinical experience was 4 years (IQR 1-9) and 45 (23%) had previous in-service training for both newborn essential and sick newborn care. Efficacy was 42% (SD ±17%). Providers averaged 78% (SD ±31%) completion of initial learning and 7% (SD ±11%) of refresher assignments. 130 (67%) providers had ≥1 episode of inactivity >30 day, no episodes were due to lack of internet access. Baseline conscious-competence was 53% (IQR: 38%-63%), unconscious-incompetence 32% (IQR: 23%-42%), conscious-incompetence 7% (IQR: 2%-15%), and unconscious-competence 2% (IQR: 0%-3%). Higher baseline conscious-competence (OR 31.6 (95% CI 5.8 to 183.5)) and being a nursing officer (aOR: 5.6 (95% CI 1.8 to 18.1)), compared with medical officer, were associated with initial learning completion or persistent activity. CONCLUSION aESNC reach was high in a population of frontline providers across diverse levels of care in Tanzania. Use of in-person support and nudging increased reach, initial learning and refresher assignment completion, but refresher assignment completion remains low. Providers were often unaware of knowledge gaps, and lower baseline knowledge may decrease initial learning completion or activity. Further study to identify barriers to adaptive e-learning normalisation is needed.
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Affiliation(s)
- Peter Andrew Meaney
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
- Critical Care, Lucile Salter Packard Children's Hospital at Stanford, Palo Alto, California, USA
| | - Adolfine Hokororo
- Pediatrics and Child Health, Bugando Consultant and Referral Hospital, Mwanza, Tanzania
- Pediatrics and Child Health, Catholic University of Health and Allied Sciences Bugando, Mwanza, Tanzania
| | - Hanston Ndosi
- Pediatrics and Child Health, Catholic University of Health and Allied Sciences Bugando, Mwanza, Tanzania
| | - Alex Dahlen
- New York University Division of Biostatistics, New York, New York, USA
| | | | - Joseph R Mwanga
- Epidemiology, Biostatistics, and Behavioural Sciences School of Public Health, Catholic University of Health and Allied Sciences Bugando, Mwanza, Tanzania
| | | | - Christine Lynn Joyce
- Critical Care, Cornell University Department of Pediatrics, New York, New York, USA
| | - Rishi Mediratta
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | | | - Marc Berg
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
- Critical Care, Lucile Salter Packard Children's Hospital at Stanford, Palo Alto, California, USA
| | - Zachary Haines Smith
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Neema Chami
- Pediatrics and Child Health, Bugando Consultant and Referral Hospital, Mwanza, Tanzania
- Pediatrics and Child Health, Catholic University of Health and Allied Sciences Bugando, Mwanza, Tanzania
| | - Namala Mkopi
- Pediatric Critical Care, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | | | - Enock Diocles
- Nursing, Mwanza College of Health and Allied Sciences, Mwanza, Tanzania
| | - Ambrose Agweyu
- Epidemiology and Demography, KEMRI-Wellcome Trust Research Institute, Nairobi, Kenya
- London School of Hygiene & Tropical Medicine, London, UK
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Muinga N, Tuti T, Mwaniki P, Gicheha E, Paton C, Beňová L, English M. Evaluating the documentation of vital signs following implementation of a new comprehensive newborn monitoring chart in 19 hospitals in Kenya: A time series analysis. PLOS Glob Public Health 2023; 3:e0002440. [PMID: 37910489 PMCID: PMC10619831 DOI: 10.1371/journal.pgph.0002440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 10/04/2023] [Indexed: 11/03/2023]
Abstract
Multi-professional teams care for sick newborns, but nurses are the primary caregivers, making nursing care documentation essential for delivering high-quality care, fostering teamwork, and improving patient outcomes. We report on an evaluation of vital signs documentation following implementation of the comprehensive newborn monitoring chart using interrupted time series analysis and a review of filled charts. We collected post-admission vital signs (Temperature (T), Pulse (P), Respiratory Rate (R) and Oxygen Saturation (S)) documentation frequencies of 43,719 newborns with a length of stay > 48 hours from 19 public hospitals in Kenya between September 2019 and October 2021. The primary outcome was an ordinal categorical variable (no monitoring, monitoring 1 to 3 times, 4 to 7 times and 8 or more times) based on the number of complete sets of TPRS. Descriptive analyses explored documentation of at least one T, P, R and S. The percentage of patients in the no-monitoring category decreased from 68.5% to 43.5% in the post-intervention period for TPRS monitoring. The intervention increased the odds of being in a higher TPRS monitoring category by 4.8 times (p<0.001) and increased the odds of higher monitoring frequency for each vital sign, with S recording the highest odds. Sicker babies were likely to have vital signs documented in a higher monitoring category and being in the NEST360 program increased the odds of frequent vital signs documentation. However, by the end of the intervention period, nearly half of the newborns did not have a single full set of TPRS documented and there was heterogenous hospital performance. A review of 84 charts showed variable documentation, with only one chart being completed as designed. Vital signs documentation fell below standards despite increased documentation odds. More sustained interventions are required to realise the benefits of the chart and hospital-specific performance data may help customise interventions.
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Affiliation(s)
- Naomi Muinga
- Athena Institute, VU University Amsterdam, Amsterdam, Netherlands
- KEMRI/Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Public Health, Institute of Tropical Medicine, Sexual and Reproductive Health Group, Antwerp, Belgium
| | - Timothy Tuti
- Athena Institute, VU University Amsterdam, Amsterdam, Netherlands
| | - Paul Mwaniki
- Athena Institute, VU University Amsterdam, Amsterdam, Netherlands
| | - Edith Gicheha
- Rice360 Global Health Institute, Rice University, Texas, United States of America
| | - Chris Paton
- Nuffield Department of Medicine, Health systems Collaborative, University of Oxford, Oxford, England
- Department of Information Science, University of Otago, Dunedin, New Zealand
| | - Lenka Beňová
- Department of Public Health, Institute of Tropical Medicine, Sexual and Reproductive Health Group, Antwerp, Belgium
| | - Mike English
- Athena Institute, VU University Amsterdam, Amsterdam, Netherlands
- Nuffield Department of Medicine, Health systems Collaborative, University of Oxford, Oxford, England
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Laur C, Ladak Z, Hall A, Solbak NM, Nathan N, Buzuayne S, Curran JA, Shelton RC, Ivers N. Sustainability, spread, and scale in trials using audit and feedback: a theory-informed, secondary analysis of a systematic review. Implement Sci 2023; 18:54. [PMID: 37885018 PMCID: PMC10604689 DOI: 10.1186/s13012-023-01312-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 10/05/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND Audit and feedback (A&F) is a widely used implementation strategy to influence health professionals' behavior that is often tested in implementation trials. This study examines how A&F trials describe sustainability, spread, and scale. METHODS This is a theory-informed, descriptive, secondary analysis of an update of the Cochrane systematic review of A&F trials, including all trials published since 2011. Keyword searches related to sustainability, spread, and scale were conducted. Trials with at least one keyword, and those identified from a forward citation search, were extracted to examine how they described sustainability, spread, and scale. Results were qualitatively analyzed using the Integrated Sustainability Framework (ISF) and the Framework for Going to Full Scale (FGFS). RESULTS From the larger review, n = 161 studies met eligibility criteria. Seventy-eight percent (n = 126) of trials included at least one keyword on sustainability, and 49% (n = 62) of those studies (39% overall) frequently mentioned sustainability based on inclusion of relevant text in multiple sections of the paper. For spread/scale, 62% (n = 100) of trials included at least one relevant keyword and 51% (n = 51) of those studies (31% overall) frequently mentioned spread/scale. A total of n = 38 studies from the forward citation search were included in the qualitative analysis. Although many studies mentioned the need to consider sustainability, there was limited detail on how this was planned, implemented, or assessed. The most frequent sustainability period duration was 12 months. Qualitative results mapped to the ISF, but not all determinants were represented. Strong alignment was found with the FGFS for phases of scale-up and support systems (infrastructure), but not for adoption mechanisms. New spread/scale themes included (1) aligning affordability and scalability; (2) balancing fidelity and scalability; and (3) balancing effect size and scalability. CONCLUSION A&F trials should plan for sustainability, spread, and scale so that if the trial is effective, the benefits can continue. A deeper empirical understanding of the factors impacting A&F sustainability is needed. Scalability planning should go beyond cost and infrastructure to consider other adoption mechanisms, such as leadership, policy, and communication, that may support further scalability. TRIAL REGISTRATION Registered with Prospero in May 2022. CRD42022332606.
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Affiliation(s)
- Celia Laur
- Women's College Hospital Institute for Health System Solutions and Virtual Care, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada.
- Institute of Health Policy, Management and Evaluation, Health Sciences Building, University of Toronto, 155 College Street, Suite 425, Toronto, ON, M5T 3M6, Canada.
| | - Zeenat Ladak
- Women's College Hospital Institute for Health System Solutions and Virtual Care, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada
- Ontario Institute for Studies in Education, University of Toronto, 252 Bloor Street West, Toronto, ON, M5S 1V6, Canada
| | - Alix Hall
- School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia
- National Centre of Implementation Science, The University of Newcastle, Newcastle, NSW, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
- Hunter New England Population Health, Hunter New England Local Health District, Newcastle, NSW, Australia
| | - Nathan M Solbak
- Physician Learning Program, Continuing Medical Education and Professional Development, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada
- Health Quality Programs, Queen's University, 92 Barrie Street, Kingston, ON, K7L 3N6, Canada
| | - Nicole Nathan
- School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia
- National Centre of Implementation Science, The University of Newcastle, Newcastle, NSW, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
- Hunter New England Population Health, Hunter New England Local Health District, Newcastle, NSW, Australia
| | - Shewit Buzuayne
- Women's College Hospital Institute for Health System Solutions and Virtual Care, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada
| | - Janet A Curran
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, NS, B3H 4R2, Canada
| | - Rachel C Shelton
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Noah Ivers
- Women's College Hospital Institute for Health System Solutions and Virtual Care, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada
- Institute of Health Policy, Management and Evaluation, Health Sciences Building, University of Toronto, 155 College Street, Suite 425, Toronto, ON, M5T 3M6, Canada
- Department of Family and Community Medicine, University of Toronto, 500 University Ave, Toronto, M5G 1V7, Canada
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Rees CA, Igunza KA, Madewell ZJ, Akelo V, Onyango D, El Arifeen S, Gurley ES, Hossain MZ, Rahman A, Alam M, Scott JAG, Assefa N, Madrid L, Belachew A, Leulseged H, Kotloff KL, Sow SO, Tapia MD, Keita AM, Sidibe D, Sitoe A, Varo R, Ajanovic S, Bassat Q, Mandomando I, Tippett Barr BA, Ogbuanu I, Cain CJ, Bassey IA, Luke R, Gassama K, Madhi S, Dangor Z, Mahtab S, Velaphi S, du Toit J, Mutevedzi PC, Blau DM, Breiman RF, Whitney CG. Provider adherence to clinical care recommendations for infants and children who died in seven low- and middle-income countries in the Child Health and Mortality Prevention Surveillance (CHAMPS) network. EClinicalMedicine 2023; 63:102198. [PMID: 37692079 PMCID: PMC10484959 DOI: 10.1016/j.eclinm.2023.102198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 08/11/2023] [Accepted: 08/18/2023] [Indexed: 09/12/2023] Open
Abstract
Background Most childhood deaths globally are considered preventable through high-quality clinical care, which includes adherence to clinical care recommendations. Our objective was to describe adherence to World Health Organization recommendations for the management of leading causes of death among children. Methods We conducted a retrospective, descriptive study examining clinical data for children aged 1-59 months who were hospitalized and died in a Child Health and Mortality Prevention Surveillance (CHAMPS) catchment, December 2016-June 2021. Catchment areas included: Baliakandi and Faridpur, Bangladesh; Kersa, Haramaya, and Harar, Ethiopia; Kisumu and Siaya, Kenya; Bamako, Mali; Manhiça and Quelimane, Mozambique; Makeni, Sierra Leone; Soweto, South Africa. We reviewed medical records of those who died from lower respiratory tract infections, sepsis, malnutrition, malaria, and diarrheal diseases to determine the proportion who received recommended treatments and compared adherence by hospitalization duration. Findings CHAMPS enrolled 460 hospitalized children who died from the leading causes (median age 12 months, 53.0% male). Median hospital admission was 31 h. There were 51.0% (n = 127/249) of children who died from lower respiratory tract infections received supplemental oxygen. Administration of intravenous fluids for sepsis (15.9%, n = 36/226) and supplemental feeds for malnutrition (14.0%, n = 18/129) were uncommon. There were 51.4% (n = 55/107) of those who died from malaria received antimalarials. Of the 80 children who died from diarrheal diseases, 76.2% received intravenous fluids. Those admitted for ≥24 h more commonly received antibiotics for lower respiratory tract infections and sepsis, supplemental feeds for malnutrition, and intravenous fluids for sepsis than those admitted <24 h. Interpretation Provision of recommended clinical care for leading causes of death among young children was suboptimal. Further studies are needed to understand the reasons for deficits in clinical care recommendation adherence. Funding Bill & Melinda Gates Foundation.
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Affiliation(s)
- Chris A. Rees
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States of America
- Children's Healthcare of Atlanta, Atlanta, GA, United States of America
| | | | - Zachary J. Madewell
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Victor Akelo
- Centers for Disease Control and Prevention-Kenya, Kisumu, Kenya
| | | | - Shams El Arifeen
- International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Emily S. Gurley
- International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Mohammad Zahid Hossain
- International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Afruna Rahman
- International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Muntasir Alam
- International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | | | - Nega Assefa
- London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
- College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Lola Madrid
- London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - Anteneh Belachew
- College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
- Hararghe Health Research, Haramaya University, Ethiopia
| | - Haleluya Leulseged
- College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
- Hararghe Health Research, Haramaya University, Ethiopia
| | - Karen L. Kotloff
- Department of Pediatrics, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Samba O. Sow
- Centre pour le Développement des Vaccins-Mali, Bamako, Mali
| | - Milagritos D. Tapia
- Department of Pediatrics, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | | | | | - Antonio Sitoe
- Centro de Investigação em Saúde de Manhiça [CISM], Maputo, Mozambique
| | - Rosauro Varo
- Centro de Investigação em Saúde de Manhiça [CISM], Maputo, Mozambique
- ISGlobal - Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Sara Ajanovic
- Centro de Investigação em Saúde de Manhiça [CISM], Maputo, Mozambique
- ISGlobal - Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Quique Bassat
- Centro de Investigação em Saúde de Manhiça [CISM], Maputo, Mozambique
- ISGlobal - Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- ICREA, Pg. Lluís Companys 23, 08010, Barcelona, Spain
- Pediatrics Department, Hospital Sant Joan de Déu, Universitat de Barcelona, Esplugues, Barcelona, Spain
- Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Inácio Mandomando
- Centro de Investigação em Saúde de Manhiça [CISM], Maputo, Mozambique
- ISGlobal - Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Instituto Nacional de Saúde, Ministério de Saúde, Maputo, Moçambique
| | | | | | | | | | - Ronita Luke
- Ministry of Health and Sanitation, Freetown, Sierra Leone
| | | | - Shabir Madhi
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Ziyaad Dangor
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Sana Mahtab
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Sithembiso Velaphi
- Department of Paediatrics and Child Health, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Jeanie du Toit
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Portia C. Mutevedzi
- Global Health Institute, Emory University, Atlanta, GA, United States of America
| | - Dianna M. Blau
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Robert F. Breiman
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Cynthia G. Whitney
- Global Health Institute, Emory University, Atlanta, GA, United States of America
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Oliwa JN, Mazhar RJ, Serem G, Khalid K, Amoth P, Kiarie H, Warfa O, Schell CO, Baker T, English M, Mcknight J. Policies and resources for strengthening of emergency and critical care services in the context of the global COVID-19 pandemic in Kenya. PLOS Glob Public Health 2023; 3:e0000483. [PMID: 37399177 DOI: 10.1371/journal.pgph.0000483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 05/19/2023] [Indexed: 07/05/2023]
Abstract
Critical illnesses cause several million deaths annually, with many of these occurring in low-resource settings like Kenya. Great efforts have been made worldwide to scale up critical care to reduce deaths from COVID-19. Lower income countries with fragile health systems may not have had sufficient resources to upscale their critical care. We aimed to review how efforts to strengthen emergency and critical care were operationalised during the pandemic in Kenya to point towards how future emergencies should be approached. This was an exploratory study that involved document reviews, and discussions with key stakeholders (donors, international agencies, professional associations, government actors), during the first year of the pandemic in Kenya. Our findings suggest that pre-pandemic health services for the critically ill in Kenya were sparse and unable to meet rising demand, with major limitations noted in human resources and infrastructure. The pandemic response saw galvanised action by the Government of Kenya and other agencies to mobilise resources (approximately USD 218 million). Earlier efforts were largely directed towards advanced critical care but since the human resource gap could not be reduced immediately, a lot of equipment remained unused. We also note that despite strong policies on what resources should be available, the reality on the ground was that there were often critical shortages. While emergency response mechanisms are not conducive to addressing long-term health system issues, the pandemic increased global recognition of the need to fund care for the critically ill. Limited resources may be best prioritised towards a public health approach with focus on provision of relatively basic, lower cost essential emergency and critical care (EECC) that can potentially save the most lives amongst critically ill patients.
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Affiliation(s)
- Jacquie Narotso Oliwa
- Department of Health Systems & Research Ethics, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics & Child Health, University of Nairobi, Nairobi, Kenya
| | - Rosanna Jeffries Mazhar
- Nuffield Department of Medicine, Health Systems Collaborative, University of Oxford, Oxford, United Kingdom
| | - George Serem
- Department of Health Systems & Research Ethics, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Karima Khalid
- Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
- Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
| | - Patrick Amoth
- Office of the Director General, Ministry of Health, Nairobi, Kenya
| | - Helen Kiarie
- Division of Monitoring and Evaluation, Ministry of Health, Nairobi, Kenya
| | - Osman Warfa
- Office of the Director General, Ministry of Health, Nairobi, Kenya
| | - Carl Otto Schell
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden
- Department of Internal Medicine, Nyköping Hospital, Nyköping, Sweden
| | - Tim Baker
- Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
- Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Mike English
- Department of Health Systems & Research Ethics, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Medicine, Health Systems Collaborative, University of Oxford, Oxford, United Kingdom
| | - Jacob Mcknight
- Nuffield Department of Medicine, Health Systems Collaborative, University of Oxford, Oxford, United Kingdom
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Gifford A, Philemon R, Halbert J, Hothersall EJ, Inglis R, Hart J, Byrne-Davis L, Thirsk J, Gifford H, Howells R, Weetch S, Prentice K, Jackson A, Kirkpatrick M. A narrative review of course evaluation methods for continuing professional development: The case of paediatric and neonatal acute-care in-service courses in low and lower-middle income countries: BEME Guide No. 76. Med Teach 2023; 45:685-697. [PMID: 36369858 DOI: 10.1080/0142159x.2022.2137010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Training a skilled healthcare workforce is an essential part in reaching the United Nations Sustainable Development Goal to end preventable deaths in children and neonates. The greatest burden of mortality lies in low and lower-middle income countries (LLMIC). Short term, in-service courses have been implemented in many LLMIC to improve the quality of care delivered, but the evaluation methods of these courses are inconsistent. METHOD Studies describing evaluations of course and outcome measures were included if the course lasted seven days or less with postgraduate participants, included paediatric or neonatal acute or emergency training and was based in a LLMIC. This narrative review provides a detailed description of evaluation methods of course content, delivery and outcome measures based on 'Context, Input, Process and Product' (CIPP) and Kirkpatrick models. RESULTS 5265 titles were screened with 93 articles included after full-text review and quality assessment. Evaluation methods are described: context, input, process, participant satisfaction, change in learning, behaviour, health system infrastructure and patient outcomes. CONCLUSIONS Outcomes, including mortality and morbidity, are rightly considered the fundamental aim of acute-care courses in LLMIC. Course evaluation can be difficult, especially with low resources, but this review outlines what can be done to guide future course organisers in providing well-conducted courses with consistent outcome measures for maximum sustainable impact.
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Affiliation(s)
| | - Rune Philemon
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Jay Halbert
- Department of Paediatrics, University College Hospital, London, England
| | | | - Rebecca Inglis
- Intensive Care Medicine, University of Oxford, Oxford, England
| | - Jo Hart
- Division of Medical Education, University of Manchester, Manchester, England
| | | | - Joanna Thirsk
- University Hospital Southampton NHS Foundation Trust, Southampton, England
| | | | - Rachel Howells
- Royal Devon and Exeter NHS Foundation Trust, Exeter, England
| | - Shona Weetch
- Clinical Development, NHS Greater Glasgow and Clyde, Glasgow, Scotland
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Orangi S, Orangi T, Kabubei KM, Honda A. Understanding factors influencing the use of clinical guidelines in low-income and middle-income settings: a scoping review. BMJ Open 2023; 13:e070399. [PMID: 37344115 DOI: 10.1136/bmjopen-2022-070399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/23/2023] Open
Abstract
OBJECTIVE A scoping review was undertaken to determine the extent to which existing studies have examined factors influencing healthcare providers' use of clinical guidelines in low and middle-income country (LMIC) settings and determine which factors constrain or facilitate the use of clinical guidelines by healthcare providers. DESIGN Scoping review. DATA SOURCES The literature search was conducted using PubMed in January 2021. ELIGIBILITY CRITERIA We identified empirical studies, published between 2011-2021 in English, which included clinicians and/or nurses as healthcare providers, used a health facility as the study site, and were located in an LMIC. DATA EXTRACTION AND SYNTHESIS Information extracted from the literature review was organised using themes and the findings synthesised using thematic analysis. RESULTS The review identified five types of interacting factors that influence healthcare providers' use of and compliance with clinical guidelines. The factors identified are organisational factors, factors relating to individual healthcare providers, attributes of the clinical guidelines, patient-related factors and institutional factors. Organisational factors can be further divided into the physical work environment, organisational culture and working conditions. The effective use of clinical guidelines in LMIC settings is greatly impacted by the contextualisation of clinical guidelines, end-user engagement and alignment of the implementation of clinical guidelines with the institutional arrangements in the broader health system. CONCLUSION The development and evaluation of concrete interventions is vital to facilitate the implementation of clinical guidelines and improve healthcare service quality. Further studies are necessary to examine the relative importance of the five identified factors on the effective use of clinical guidelines in different contexts.
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Affiliation(s)
- Stacey Orangi
- Health Economics Research Unit (HERU), KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Tiffany Orangi
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Ayako Honda
- Research Center for Health Policy and Economics, Hitotsubashi Institute for Advanced Study, Hitotsubashi University, Tokyo, Japan
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Shah HA, Baker T, Schell CO, Kuwawenaruwa A, Awadh K, Khalid K, Kairu A, Were V, Barasa E, Baker P, Guinness L. Cost Effectiveness of Strategies for Caring for Critically Ill Patients with COVID-19 in Tanzania. Pharmacoecon Open 2023:10.1007/s41669-023-00418-x. [PMID: 37178434 PMCID: PMC10181924 DOI: 10.1007/s41669-023-00418-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND The resources for critical care are limited in many settings, exacerbating the significant morbidity and mortality associated with critical illness. Budget constraints can lead to choices between investing in advanced critical care (e.g. mechanical ventilators in intensive care units) or more basic critical care such as Essential Emergency and Critical Care (EECC; e.g. vital signs monitoring, oxygen therapy, and intravenous fluids). METHODS We investigated the cost effectiveness of providing EECC and advanced critical care in Tanzania in comparison with providing 'no critical care' or 'district hospital-level critical care' using coronavirus disease 2019 (COVID-19) as a tracer condition. We developed an open-source Markov model ( https://github.com/EECCnetwork/POETIC_CEA ) to estimate costs and disability-adjusted life-years (DALYs) averted, using a provider perspective, a 28-day time horizon, patient outcomes obtained from an elicitation method involving a seven-member expert group, a normative costing study, and published literature. We performed a univariate and probabilistic sensitivity analysis to assess the robustness of our results. , RESULTS EECC is cost effective 94% and 99% of the time when compared with no critical care (incremental cost-effectiveness ratio [ICER] $37 [-$9 to $790] per DALY averted) and district hospital-level critical care (ICER $14 [-$200 to $263] per DALY averted), respectively, relative to the lowest identified estimate of the willingness-to-pay threshold for Tanzania ($101 per DALY averted). Advanced critical care is cost effective 27% and 40% of the time, when compared with the no critical care or district hospital-level critical care scenarios, respectively. CONCLUSION For settings where there is limited or no critical care delivery, implementation of EECC could be a highly cost-effective investment. It could reduce mortality and morbidity for critically ill COVID-19 patients, and its cost effectiveness falls within the range considered 'highly cost effective'. Further research is needed to explore the potential of EECC to generate even greater benefits and value for money when patients with diagnoses other than COVID-19 are accounted for.
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Affiliation(s)
| | - Tim Baker
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
- Ifakara Health Institute, Dar es Salaam, Tanzania
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Carl Otto Schell
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden
- Department of Medicine, Nyköping Hospital, Nyköping, Sweden
| | | | - Khamis Awadh
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Karima Khalid
- Ifakara Health Institute, Dar es Salaam, Tanzania
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Angela Kairu
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
| | - Vincent Were
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
- Center for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Lorna Guinness
- Center for Global Development, London, UK.
- Global Health Economics Centre, London School of Hygiene and Tropical Medicine, London, UK.
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Nyawira L, Njuguna RG, Tsofa B, Musiega A, Munywoki J, Hanson K, Mulwa A, Molyneux S, Maina I, Normand C, Jemutai J, Barasa E. Examining the influence of health sector coordination on the efficiency of county health systems in Kenya. BMC Health Serv Res 2023; 23:355. [PMID: 37041505 PMCID: PMC10091577 DOI: 10.1186/s12913-023-09344-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 03/27/2023] [Indexed: 04/13/2023] Open
Abstract
BACKGROUND Health systems are complex, consisting of multiple interacting structures and actors whose effective coordination is paramount to enhancing health system goals. Health sector coordination is a potential source of inefficiency in the health sector. We examined how the coordination of the health sector affects health system efficiency in Kenya. METHODS We conducted a qualitative cross-sectional study, collecting data at the national level and in two purposely selected counties in Kenya. We collected data using in-depth interviews (n = 37) with national and county-level respondents, and document reviews. We analyzed the data using a thematic approach. RESULTS The study found that while formal coordination structures exist in the Kenyan health system, duplication, fragmentation, and misalignment of health system functions and actor actions compromise the coordination of the health sector. These challenges were observed in both vertical (coordination within the ministry of health, within the county departments of health, and between the national ministry of health and the county department of health) and horizontal coordination mechanisms (coordination between the ministry of health or the county department of health and non-state partners, and coordination among county governments). These coordination challenges are likely to impact the efficiency of the Kenyan health system by increasing the transaction costs of health system functions. Inadequate coordination also impairs the implementation of health programmes and hence compromises health system performance. CONCLUSION The efficiency of the Kenyan health system could be enhanced by strengthening the coordination of the Kenyan health sector. This can be achieved by aligning and harmonizing the intergovernmental and health sector-specific coordination mechanisms, strengthening the implementation of the Kenya health sector coordination framework at the county level, and enhancing donor coordination through common funding arrangements and integrating vertical disease programs with the rest of the health system. The ministry of health and county departments of health should also review internal organizational structures to enhance functional and role clarity of organizational units and staff, respectively. Finally, counties should consider initiating health sector coordination mechanisms between counties to reduce the fragmentation of health system functions across neighboring counties.
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Affiliation(s)
- Lizah Nyawira
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Rebecca G Njuguna
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Benjamin Tsofa
- Health Systems and Research Ethics Department, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Anita Musiega
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Joshua Munywoki
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Kara Hanson
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Andrew Mulwa
- Directorate of Medical Services, preventive and promotive health, Ministry of Health, Nairobi, Kenya
| | - Sassy Molyneux
- Health Systems and Research Ethics Department, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Isabel Maina
- Health Financing Department, Ministry of Health, Nairobi, Kenya
| | - Charles Normand
- Centre for Health Policy and Management, Trinity College, the University of Dublin, Dublin, Ireland
| | - Julie Jemutai
- Health Systems and Research Ethics Department, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
- Institute of Healthcare Management, Strathmore Business School, Strathmore University, Nairobi, Kenya.
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Albarqouni L, Palagama S, Chai J, Sivananthajothy P, Pathirana T, Bakhit M, Arab-Zozani M, Ranakusuma R, Cardona M, Scott A, Clark J, Smith CF, Effa E, Ochodo E, Moynihan R. Overuse of medications in low- and middle-income countries: a scoping review. Bull World Health Organ 2023; 101:36-61D. [PMID: 36593777 PMCID: PMC9795388 DOI: 10.2471/blt.22.288293] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 08/09/2022] [Accepted: 08/10/2022] [Indexed: 01/04/2023] Open
Abstract
Objective To identify and summarize the evidence about the extent of overuse of medications in low- and middle-income countries, its drivers, consequences and potential solutions. Methods We conducted a scoping review by searching the databases PubMed®, Embase®, APA PsycINFO® and Global Index Medicus using a combination of MeSH terms and free text words around overuse of medications and overtreatment. We included studies in any language published before 25 October 2021 that reported on the extent of overuse, its drivers, consequences and solutions. Findings We screened 3489 unique records and included 367 studies reporting on over 5.1 million prescriptions across 80 low- and middle-income countries - with studies from 58.6% (17/29) of all low-, 62.0% (31/50) of all lower-middle- and 60.0% (33/55) of all upper-middle-income countries. Of the included studies, 307 (83.7%) reported on the extent of overuse of medications, with estimates ranging from 7.3% to 98.2% (interquartile range: 30.2-64.5). Commonly overused classes included antimicrobials, psychotropic drugs, proton pump inhibitors and antihypertensive drugs. Drivers included limited knowledge of harms of overuse, polypharmacy, poor regulation and financial influences. Consequences were patient harm and cost. Only 11.4% (42/367) of studies evaluated solutions, which included regulatory reforms, educational, deprescribing and audit-feedback initiatives. Conclusion Growing evidence suggests overuse of medications is widespread within low- and middle-income countries, across multiple drug classes, with few data of solutions from randomized trials. Opportunities exist to build collaborations to rigorously develop and evaluate potential solutions to reduce overuse of medications.
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Affiliation(s)
- Loai Albarqouni
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, 14 University Dr, Robina, QLD, 4229, Australia
| | - Sujeewa Palagama
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, 14 University Dr, Robina, QLD, 4229, Australia
| | - Julia Chai
- Cumming School of Medicine, University of Calgary, Alberta, Canada
| | | | - Thanya Pathirana
- School of Medicine and Dentistry, Griffith University, Sunshine Coast, Australia
| | - Mina Bakhit
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, 14 University Dr, Robina, QLD, 4229, Australia
| | - Morteza Arab-Zozani
- Social Determinants of Health Research Center, Birjand University of Medical Sciences, Birjand, Iran
| | - Respati Ranakusuma
- Clinical Epidemiology and Evidence-Based Medicine Unit, Dr Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Magnolia Cardona
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, 14 University Dr, Robina, QLD, 4229, Australia
| | - Anna Scott
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, 14 University Dr, Robina, QLD, 4229, Australia
| | - Justin Clark
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, 14 University Dr, Robina, QLD, 4229, Australia
| | | | - Emmanuel Effa
- Department of Internal Medicine, University of Calabar, Calabar, Nigeria
| | - Eleanor Ochodo
- Centre for Global Health Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Ray Moynihan
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, 14 University Dr, Robina, QLD, 4229, Australia
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Meaney PA, Hokororo A, Masenge T, Mwanga J, Kalabamu FS, Berg M, Rozenfeld B, Smith Z, Chami N, Mkopi N, Mwanga C, Agweyu A. Development of pediatric acute care education (PACE): An adaptive electronic learning (e-learning) environment for healthcare providers in Tanzania. Digit Health 2023; 9:20552076231180471. [PMID: 37529543 PMCID: PMC10387696 DOI: 10.1177/20552076231180471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 05/19/2023] [Indexed: 08/03/2023] Open
Abstract
Globally, inadequate healthcare provider (HCP) proficiency with evidence-based guidelines contributes to millions of newborn, infant, and child deaths each year. HCP guideline proficiency would improve patient outcomes. Conventional (in person) HCP in-service education is limited in 4 ways: reach, scalability, adaptability, and the ability to contextualize. Adaptive e-learning environments (AEE), a subdomain of e-learning, incorporate artificial intelligence technology to create a unique cognitive model of each HCP to improve education effectiveness. AEEs that use existing internet access and personal mobile devices may overcome limits of conventional education. This paper provides an overview of the development of our AEE HCP in-service education, Pediatric Acute Care Education (PACE). PACE uses an innovative approach to address HCPs' proficiency in evidence-based guidelines for care of newborns, infants, and children. PACE is novel in 2 ways: 1) its patient-centric approach using clinical audit data or frontline provider input to determine content and 2) its ability to incorporate refresher learning over time to solidify knowledge gains. We describe PACE's integration into the Pediatric Association of Tanzania's (PAT) Clinical Learning Network (CLN), a multifaceted intervention to improve facility-based care along a single referral chain. Using principles of co-design, stakeholder meetings modified PACE's characteristics and optimized integration with CLN. We plan to use three-phase, mixed-methods, implementation process. Phase I will examine the feasibility of PACE and refine its components and protocol. Lessons gained from this initial phase will guide the design of Phase II proof of concept studies which will generate insights into the appropriate empirical framework for (Phase III) implementation at scale to examine effectiveness.
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Key Words
- eHealth, general, digital health, general education, lifestyle, smartphone, media paediatrics, medicine, mHealth, psychology, mixed methods, studies
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Affiliation(s)
- Peter Andrew Meaney
- Department of Pediatrics, Stanford University School of Medicine, Pediatrics, Palo Alto, CA, USA
| | - Adolfine Hokororo
- Department of Pediatrics, Catholic University of Health and Allied Sciences Bugando, Pediatrics, Mwanza, Tanzania
| | | | - Joseph Mwanga
- Catholic University of Health and Allied Sciences School of Public Health, Mwanza, Tanzania
| | | | - Marc Berg
- Department of Pediatrics, Stanford University School of Medicine, Pediatrics, Palo Alto, CA, USA
| | | | - Zachary Smith
- Department of Pediatrics, Stanford University School of Medicine, Pediatrics, Palo Alto, CA, USA
| | - Neema Chami
- Department of Pediatrics, Catholic University of Health and Allied Sciences Bugando, Pediatrics, Mwanza, Tanzania
| | - Namala Mkopi
- Department of Pediatrics, Muhimbili University of Health and Allied Sciences School of Medicine, Pediatrics, Dar Es Salaam, Tanzania
| | - Castory Mwanga
- Department of Pediatrics, Simiyu District Hospital, Pediatrics, Simiyu, Tanzania
| | - Ambrose Agweyu
- Department of Infectious Disease and Epidemiology, London School of Hygiene and Tropical Medicine, Infectious Disease Epidemiology, Nairobi, Kenya
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15
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Werner K, Risko N, Kalanzi J, Wallis LA, Reynolds TA. Cost-effectiveness analysis of the multi-strategy WHO emergency care toolkit in regional referral hospitals in Uganda. PLoS One 2022; 17:e0279074. [PMID: 36516176 PMCID: PMC9750003 DOI: 10.1371/journal.pone.0279074] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 11/30/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Low- and middle-income countries bear a disproportionate amount of the global burden of disease from emergency conditions. To improve the provision of emergency care in low-resource settings, a multifaceted World Health Organization (WHO) intervention introduced a toolkit including Basic Emergency Care training, resuscitation area guidelines, a trauma registry, a trauma checklist, and triage tool in two public hospital sites in Uganda. While introduction of the toolkit revealed a large reduction in the case fatality rate of patients, little is known about the cost-effectiveness and affordability. We analysed the cost-effectiveness of the toolkit and conducted a budget analysis to estimate the impact of scale up to all regional referral hospitals for the national level. METHODS A decision tree model was constructed to assess pre- and post-intervention groups from a societal perspective. Data regarding mortality were drawn from WHO quality improvement reports captured at two public hospitals in Uganda from 2016-2017. Cost data were drawn from project budgets and included direct costs of the implementation of the intervention, and direct costs of clinical care for patients with disability. Development costs were not included. Parameter uncertainty was assessed using both deterministic and probabilistic sensitivity analyses. Our model estimated the incremental cost-effectiveness of implementing the WHO emergency care toolkit measuring all costs and outcomes as disability-adjusted life-years (DALYs) over a lifetime, discounting both costs and outcomes at 3.5%. RESULTS Implementation of the WHO Toolkit averted 1,498 DALYs when compared to standard care over a one-year time horizon. The initial investment of $5,873 saved 34 lives (637 life years) and avoided $1,670,689 in downstream societal costs, resulted in a negative incremental cost-effectiveness ratio, dominating the comparator scenario of no intervention. This would increase to saving 884 lives and 25,236 DALYs annually with national scale up. If scaled to a national level the total intervention cost over period of five years would be $4,562,588 or a 0.09% increase of the total health budget for Uganda. The economic gains are estimated to be $29,880,949 USD, the equivalent of a 655% return on investment. The model was most sensitive to average annual cash income, discount rate and frequency survivor is a road-traffic incident survivor, but was robust for all other parameters. CONCLUSION Improving emergency care using the WHO Toolkit produces a cost-savings in a low-resource setting such as Uganda. In alignment with the growing body of literature highlighting the value of systematizing emergency care, our findings suggest the toolkit could be an efficient approach to strengthening emergency care systems.
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Affiliation(s)
- Kalin Werner
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
- * E-mail:
| | - Nicholas Risko
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | | | - Lee A. Wallis
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Teri A. Reynolds
- Department for Clinical Services and Systems, Integrated Health Services, World Health Organization (WHO), Geneva, Switzerland
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16
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Quartagno M, Carpenter JR. Substantive model compatible multilevel multiple imputation: A joint modeling approach. Stat Med 2022; 41:5000-5015. [PMID: 35959539 DOI: 10.1002/sim.9549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 05/03/2022] [Accepted: 07/25/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Substantive model compatible multiple imputation (SMC-MI) is a relatively novel imputation method that is particularly useful when the analyst's model includes interactions, non-linearities, and/or partially observed random slope variables. METHODS Here we thoroughly investigate a SMC-MI strategy based on joint modeling of the covariates of the analysis model. We provide code to apply the proposed strategy and we perform an extensive simulation work to test it in various circumstances. We explore the impact on the results of various factors, including whether the missing data are at the individual or cluster level, whether there are non-linearities and whether the imputation model is correctly specified. Finally, we apply the imputation methods to the motivating example data. RESULTS SMC-JM appears to be superior to standard JM imputation, particularly in presence of large variation in random slopes, non-linearities, and interactions. Results seem to be robust to slight mis-specification of the imputation model for the covariates. When imputing level 2 data, enough clusters have to be observed in order to obtain unbiased estimates of the level 2 parameters. CONCLUSIONS SMC-JM is preferable to standard JM imputation in presence of complexities in the analysis model of interest, such as non-linearities or random slopes.
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Affiliation(s)
- Matteo Quartagno
- Institute for Clinical Trials and Methodology, University College London, London, UK
| | - James R Carpenter
- Institute for Clinical Trials and Methodology, University College London, London, UK.,Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
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17
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Sayarifard A, Nazari M, Bahmanziari N, Mehrdad N, Ghadirian L. Challenges of Clinical Practice Guidelines Adaptation in Iran: Lesson learned for Low and Middle-Income Countries. Med J Islam Repub Iran 2022; 36:71. [PMID: 36128294 PMCID: PMC9448469 DOI: 10.47176/mjiri.36.71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 06/29/2022] [Indexed: 11/09/2022] Open
Abstract
Background: Developing a clinical practice guideline (CPG) is very time-consuming, expensive, and requires specialized knowledge; therefore, when an up-to-date and quality CPG is available, it is logical to adapt it according to local conditions. So this study aimed to identify the challenges of CPGs adaptation in Iran to help improve it and provide lessons for low and middle-income countries (LMICs). Methods: This was a qualitative study that was conducted in 2019. Semi-structured interviews were conducted with 17 participants from two levels, groups involved in the CPGs adaptation process, from research centers and specialized medical associations and policymakers and planners in CPG development and adaptation from the Ministry of Health and Medical Education (MoHME). Results: The identified challenges were classified into two basic and operational categories. Basic challenges include believing the need for CPGs adaptation, attention to CPGs adaptation in evaluation and reward systems, access to financial resources, and supervision of the adaptation process. Also, operational challenges were adaptation methodology, forming an adaptation team, consensus on interdisciplinary issues, changing programs and priorities, and external barriers in the work progress path. Conclusion: The main challenges of CPGs adaptation in Iran, as one of the LMICs, are related to education, financing, and supervision of adaptation process steps. The most significant proposed interventions to overcome the current obstacles in countries with similar contexts are holding new training courses and programs for these CPG users at different headquarters' and environmental levels, establishing an appropriate motivating system, designing an integrated adaptation system focusing on organizing related supervision affairs like planning, policy-making, and supervision at the MoHME and universities level.
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Affiliation(s)
- Azadeh Sayarifard
- Knowledge Utilization Research Center, Center for Academic and Health Policy, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Nazari
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Najmeh Bahmanziari
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Neda Mehrdad
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran,Knowledge Utilization Research Center, Center for Academic and Health Policy, Tehran University of Medical Sciences, Tehran, Iran
| | - Laleh Ghadirian
- Knowledge Utilization Research Center, Center for Academic and Health Policy, Tehran University of Medical Sciences, Tehran, Iran,Corresponding author: Dr Laleh Ghadirian,
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18
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Kirchner JE, Dollar KM, Smith JL, Pitcock JA, Curtis ND, Morris KK, Fletcher TL, Topor DR. Development and Preliminary Evaluation of an Implementation Facilitation Training Program. Implementation Research and Practice 2022; 3:26334895221087475. [PMID: 37091085 PMCID: PMC9924286 DOI: 10.1177/26334895221087475] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Implementation scientists are identifying evidence-based implementation strategies that support the uptake of evidence-based practices and other clinical innovations. However, there is limited information regarding the development of training methods to educate implementation practitioners on the use of implementation strategies and help them sustain these competencies. Methods: To address this need, we developed, implemented, and evaluated a training program for one strategy, implementation facilitation (IF), that was designed to maximize applicability in diverse clinical settings. Trainees included implementation practitioners, clinical managers, and researchers. From May 2017 to July 2019, we sent trainees an electronic survey via email and asked them to complete the survey at three-time points: approximately 2 weeks before and 2 weeks and 6 months after each training. Participants ranked their knowledge of and confidence in applying IF skills using a 4-point Likert scale. We compared scores at baseline to post-training and at 6 months, as well as post-training to 6 months post-training (nonparametric Wilcoxon signed-rank tests). Results: Of the 102 participants (76 in-person, 26 virtual), there was an increase in perceived knowledge and confidence in applying IF skills across all learning objectives from pre- to post-training (95% response rate) and pre- to 6-month (35% response rate) follow-up. There was no significant difference in results between virtual and in-person trainees. When comparing post-training to 6 months (30% response rate), perceptions of knowledge increase remained unchanged, although participants reported reduced perceived confidence in applying IF skills for half of the learning objectives at 6 months. Conclusions: Findings indicated that we have developed a promising IF training program. Lack of differences in results between virtual and in-person participants indicated the training can be provided to a remote site without loss of knowledge/skills transfer but ongoing support may be needed to help sustain perceived confidence in applying these skills. Plain Language Summary While implementation scientists are documenting an increasing number of implementation strategies that support the uptake of evidence-based practices and other clinical innovations, little is known about how to transfer this knowledge to those who conduct implementation efforts in the frontline clinical practice settings. We developed, implemented, and conducted a preliminary evaluation of a training program for one strategy, implementation facilitation (IF). The training program targets facilitation practitioners, clinical managers, and researchers. This paper describes the development of the training program, the program components, and the results from an evaluation of IF knowledge and skills reported by a subset of people who participated in the training. Findings from the evaluation indicate that this training program significantly increased trainees' perceived knowledge of and confidence in applying IF skills. Further research is needed to examine whether ongoing mentoring helps trainees retain confidence in applying some IF skills over the longer term.
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Affiliation(s)
- JoAnn E. Kirchner
- Department of Veterans Affairs, VA Behavioral Health Quality Enhancement Research Initiative (QUERI), North Little Rock, AR, USA
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | - Jeffrey L. Smith
- Department of Veterans Affairs, VA Behavioral Health Quality Enhancement Research Initiative (QUERI), North Little Rock, AR, USA
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jeffery A. Pitcock
- Department of Veterans Affairs, VA Behavioral Health Quality Enhancement Research Initiative (QUERI), North Little Rock, AR, USA
| | - Nyssa D. Curtis
- Department of Veterans Affairs, VA Behavioral Health Quality Enhancement Research Initiative (QUERI), North Little Rock, AR, USA
| | - Krissi K. Morris
- Department of Veterans Affairs, VA Behavioral Health Quality Enhancement Research Initiative (QUERI), North Little Rock, AR, USA
| | - Terri L. Fletcher
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA
- Baylor College of Medicine, Houston, TX, USA
- VA South Central Mental Illness Research, Education and Clinical Center (A Virtual Center), Houston, TX, USA
| | - David R. Topor
- VA Boston Healthcare System, Brockton, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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19
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Amboko B, Stepniewska K, Machini B, Bejon P, Snow RW, Zurovac D. Factors influencing health workers' compliance with outpatient malaria 'test and treat' guidelines during the plateauing performance phase in Kenya, 2014-2016. Malar J 2022; 21:68. [PMID: 35241074 PMCID: PMC8895910 DOI: 10.1186/s12936-022-04093-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 02/17/2022] [Indexed: 11/12/2022] Open
Abstract
Background Health workers’ compliance with outpatient malaria ‘test and treat’ guidelines has improved since 2010 but plateaued from 2014 at suboptimal levels in Kenya. This study examined the factors associated with high but suboptimal compliance levels at facilities with available malaria tests and drugs. Methods Data from four national, cross-sectional health facility surveys undertaken between 2014 and 2016 in Kenya were analysed. Association between 31 factors and compliance with malaria testing (survey range (SR): 65–69%) and no anti-malarial treatment for test negative patients (SR: 90–92%) were examined using multilevel logistic regression models. Results A total of 2,752 febrile patients seen by 594 health workers at 486 health facilities were analysed. Higher odds of malaria testing were associated with lake endemic (aOR = 12.12; 95% CI: 5.3–27.6), highland epidemic (aOR = 5.06; 95% CI: 2.7–9.5) and semi-arid seasonal (aOR = 2.07; 95% CI: 1.2–3.6) compared to low risk areas; faith-based (FBO)/ non-governmental organization (NGO)-owned compared to government-owned facilities (aOR = 5.80; 95% CI: 3.2–10.6); health workers’ perception of malaria endemicity as high-risk (aOR = 3.05; 95% CI: 1.8–5.2); supervision with feedback (aOR = 1.84; 95% CI: 1.2–2.9); access to guidelines (aOR = 1.96; 95% CI: 1.1–3.4); older patients compared to infants, higher temperature measurements and main complaints of fever, diarrhoea, headache, vomiting and chills. Lower odds of testing were associated with febrile patients having main complaints of a cough (aOR = 0.65; 95% CI: 0.5–0.9), a rash (aOR = 0.32; 95% CI: 0.2–0.7) or a running nose (aOR = 0.59; 95% CI: 0.4–0.9). Other factors associated with compliance with test negative results included the type of diagnostic test available at the facility, in-service training, health workers’ age, and correct knowledge of the targeted treatment policy. Conclusions To optimize outpatient malaria case-management, reduce testing compliance gaps and eliminate overtreatment of test negative patients, there is a need to focus on compliance within low malaria risk areas in addition to ensuring the universal and continuous availability of ‘test and treat’ commodities. Targeting of older and government health workers; dissemination of updated guidelines; and continuing with in-service training and supportive supervision with feedback is essential. Lastly, there is a need to improve health workers’ knowledge about malaria testing criteria considering their perceptions of endemicity. Supplementary Information The online version contains supplementary material available at 10.1186/s12936-022-04093-x.
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Affiliation(s)
- Beatrice Amboko
- KEMRI-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya.
| | - Kasia Stepniewska
- WorldWide Antimalarial Resistance Network, Oxford, UK.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Beatrice Machini
- Division of National Malaria Programme, Ministry of Health, Nairobi, Kenya
| | - Philip Bejon
- KEMRI-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Robert W Snow
- KEMRI-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Dejan Zurovac
- KEMRI-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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20
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Safe M, Wittick P, Philaketh K, Manivong A, Gray A. Mixed‐methods evaluation of a continuing education approach to improving district hospital care for children in Lao PDR. Trop Med Int Health 2022; 27:262-270. [PMID: 35080283 PMCID: PMC9305739 DOI: 10.1111/tmi.13726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objective To understand the impact of a multifaceted intervention on improving acute hospital care provided to children in two district hospitals in northern Lao PDR. Methods We developed a continuing education intervention, which integrated separate program content using a common pool of facilitators and low‐fidelity simulation scenarios. Coaching was delivered over one year through two‐day hospital visits to each hospital six to eight weeks apart with visits incorporating feedback. A comparative case study was conducted between two hospital sites. Medical record abstraction from inpatient cases was performed at each visit. Focus groups and interviews with staff were conducted to understand perceived changes to case management. Results Inpatient case management scores showed incremental improvement over time, from 50% at baseline to 80% at the end of one year at Hospital A and 52% to 97% at Hospital B. The key themes that emerged from the qualitative data from both hospitals were the value of the educational method and increased belief in capability. Hospital B showed more incremental and sustained improvement. Qualitative data revealed that the directors of Hospital B demonstrated modelling and behavioural reinforcement. Conclusion Improving the quality of care in low‐resource settings is feasible. A hands‐on practical approach with repeated coaching visits reinforced by feedback can lead to behaviour change. Optimal impact requires harnessing leadership and motivation for change among health workers.
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Affiliation(s)
- Marianne Safe
- Department of Paediatrics University of Melbourne Melbourne Australia
| | - Penelope Wittick
- Department of Paediatrics University of Melbourne Melbourne Australia
| | - Khammanh Philaketh
- Primary Health Care Program Office Save the Children, Luang Prabang, Lao PDR
| | | | - Amy Gray
- Department of Paediatrics University of Melbourne Melbourne Australia
- The Royal Children’s Hospital Melbourne Australia
- Murdoch Children’s Research Institute Melbourne Australia
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21
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Firew T, Mishra D, Makonnen T, Fantaye HH, Workeye B, Kebede S, Ebrahim Yimer F, Abebe Y, Shiferaw B, Gebreyesus A, Sultan M, Azazh A. Emergency capacity analysis in Ethiopia: Results of a baseline emergency facility assessment. PLoS One 2022; 17:e0258310. [PMID: 35061664 PMCID: PMC8782317 DOI: 10.1371/journal.pone.0258310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 09/23/2021] [Indexed: 11/18/2022] Open
Abstract
Introduction In Ethiopia, the specialty of Emergency Medicine is a relatively new discipline. In the last few decades, policymakers have made Emergency Medicine a priority for improving population health. This study aims to contribute to this strengthening of Emergency Medicine, by conducting the country’s first baseline gap analysis of Emergency Medicine Capacity at the pre-hospital and hospital level in order to help identify needs and areas for intervention. Methods This is a cross sectional investigation that utilized a convenience sampling of 22 primary, general and tertiary hospitals. Trained personnel visited the hospitals and conducted 4-hour interviews with hospital administrators and emergency care area personnel. The tool used in the interview was the Columbia University sidHARTe Program Emergency Services Resource Assessment Tool (ESRAT) to evaluate both emergency and trauma capacity in different regions of Ethiopia. The findings of this survey were then compared against two established standards: the World Health Organization’s Essential Package of Emergency Care (EPEC), as well as those set by Ethiopia’s Federal Ministry of Health. Results The tool assessed the services provided at each hospital and evaluated the infrastructure of emergency care at the facility. Triage systems differed amongst the hospitals surveyed though triaging and emergency unit infrastructures were relatively similar amongst the hospitals. There was a marked variability in the level of training, guidelines, staffing, disaster preparedness, drug availability, procedures performed, and quality assurance measures from hospital to hospital. Most regional and district hospitals did not have nurses or doctors trained in Emergency Medicine and over 70% of the hospitals did not have written guidelines for standardized emergency care. Conclusion This gap analysis has revealed numerous inconsistencies in health care practice, resources, and infrastructure within the scope of Emergency Medicine in Ethiopia. Major gaps were identified, and the results of this assessment were used to devise action priorities for the Ministry of Health. Much remains to be done to strengthen Emergency Medicine in Ethiopia, and numerous opportunities exist to make additional short and long-term improvements.
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Affiliation(s)
- Tsion Firew
- Columbia University Irving Medical Center, New York City, NY, United States of America
| | - Diksha Mishra
- Weill Cornell Medical Center, New York City, NY, United States of America
- * E-mail:
| | - Tirsit Makonnen
- Cooper University Healthcare Center, Camden, NJ, United States of America
| | | | | | | | | | - Yonas Abebe
- St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | | | | | - Menbeu Sultan
- St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
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22
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Tuti T, Aluvaala J, Chelangat D, Mbevi G, Wainaina J, Mumelo L, Wairoto K, Mochache D, Irimu G, Maina M, English M. Improving in-patient neonatal data quality as a pre-requisite for monitoring and improving quality of care at scale: A multisite retrospective cohort study in Kenya. PLOS Glob Public Health 2022; 2:e0000673. [PMID: 36962543 PMCID: PMC10021237 DOI: 10.1371/journal.pgph.0000673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 09/20/2022] [Indexed: 03/11/2023]
Abstract
The objectives of this study were to (1)explore the quality of clinical data generated from hospitals providing in-patient neonatal care participating in a clinical information network (CIN) and whether data improved over time, and if data are adequate, (2)characterise accuracy of prescribing for basic treatments provided to neonatal in-patients over time. This was a retrospective cohort study involving neonates ≤28 days admitted between January 2018 and December 2021 in 20 government hospitals with an interquartile range of annual neonatal inpatient admissions between 550 and 1640 in Kenya. These hospitals participated in routine audit and feedback processes on quality of documentation and care over the study period. The study's outcomes were the number of patients as a proportion of all eligible patients over time with (1)complete domain-specific documentation scores, and (2)accurate domain-specific treatment prescription scores at admission, reported as incidence rate ratios. 80,060 neonatal admissions were eligible for inclusion. Upon joining CIN, documentation scores in the monitoring, other physical examination and bedside testing, discharge information, and maternal history domains demonstrated a statistically significant month-to-month relative improvement in number of patients with complete documentation of 7.6%, 2.9%, 2.4%, and 2.0% respectively. There was also statistically significant month-to-month improvement in prescribing accuracy after joining the CIN of 2.8% and 1.4% for feeds and fluids but not for Antibiotic prescriptions. Findings suggest that much of the variation observed is due to hospital-level factors. It is possible to introduce tools that capture important clinical data at least 80% of the time in routine African hospital settings but analyses of such data will need to account for missingness using appropriate statistical techniques. These data allow exploration of trends in performance and could support better impact evaluation, exploration of links between health system inputs and outcomes and scrutiny of variation in quality and outcomes of hospital care.
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Affiliation(s)
- Timothy Tuti
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Jalemba Aluvaala
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | | | - George Mbevi
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - John Wainaina
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | - Kefa Wairoto
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | - Grace Irimu
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Michuki Maina
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | - Mike English
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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Hands C, Hands S, Verriotis M, Bunn J, Bailey E, Samuels RJ, Sankoh K, Mustapha A, Williams B, Taylor S. Emergency Triage Assessment and Treatment Plus (ETAT+): adapting training to strengthen quality improvement and task-sharing in emergency paediatric care in Sierra Leone. J Glob Health 2021; 11:04069. [PMID: 34956636 PMCID: PMC8684797 DOI: 10.7189/jogh.11.04069] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Over the past 25 years Sierra Leone has made progress in reducing maternal and child mortality, but the burden of preventable paediatric deaths remains high. Further progress towards achieving the Sustainable Development Goals will require greater strengthening of the health care system, including hospital care for perinatal and paediatric conditions. Emergency Triage Assessment and Treatment Plus (ETAT+) may offer a useful tool. Methods The five-day ETAT+ course was adapted as a six-month programme of in-situ training and mentoring integrated with patient flow and service delivery improvements in 14 regional and district government hospitals across the country. Nurses were trained to carry out the initial resuscitation and assessment of the sick paediatric patient, and to administer the first dose of medication per protocol. The course was for all clinical staff; most participants were nurses. Results The intervention was associated with an improvement in the quality of paediatric care and a reduction in mortality. In 2017 mortality decreased by 33.1%, from 14.5% at baseline to 9.7% after six months of the intervention. Mortality at the start of the 2018 intervention was 8.5% and reduced over six months to 6.5%. Care quality indicators showed improvement across the two intervention periods, with some evidence of sustained effect. Conclusions These results suggest that adapted ETAT+ training with in-situ mentoring alongside improved patient flow and service delivery supports improvements in the quality of paediatric care in Sierra Leonean hospitals. ETAT+ may provide an affordable framework for improving the quality of secondary paediatric care in Sierra Leone and a model of nurse-led resuscitation may allow for prompt and timely emergency paediatric care in Sierra Leonean hospitals where there are fewer physicians and other resources for care.
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Affiliation(s)
| | - Sandra Hands
- Royal College of Paediatrics and Child Health, London, UK
| | | | - James Bunn
- World Health Organisation, Freetown, Sierra Leone
| | - Emma Bailey
- Royal College of Paediatrics and Child Health, London, UK
| | | | - Kadiatu Sankoh
- Ministry of Health and Sanitation, Freetown, Sierra Leone
| | | | - Bhanu Williams
- Royal College of Paediatrics and Child Health, London, UK
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Ogunbiyi O, Sanusi A, Osinaike B, Yakubu S, Rotimi M, Fatungase O. An overview of intensive care unit services in Nigeria. J Crit Care 2021; 66:160-165. [PMID: 34330559 DOI: 10.1016/j.jcrc.2021.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/06/2021] [Accepted: 07/07/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE To have a current overview of the state of critical care services in Nigeria, with a view to having information about the basic infrastructure, personnel, equipment, and processes in place to complement the acute peri-operative and medical emergencies in Nigeria. MATERIALS AND METHODS This was a cross-sectional survey of public and private intensive care units (ICUs) in Nigeria at the instance of the Intensive and Critical Care Society of Nigeria. Structured questionnaires were sent and collated over a 4-month period. Information on the institutions, ICU equipment and personnel were collected and analyzed using SPSS version 21(Chicago, Illinois). Data are presented in numbers, percentages, medians, and interquartile ranges (IQR) as appropriate. RESULTS A total of 30 ICUs spread within all the six geo-political zones in Nigeria took part in this survey. Majority (63.3%) of them were located in teaching hospitals. The median number of ICU beds and equipment in hospitals surveyed were beds, 5(4-6), ventilators, 3 (1-4); multiparameter monitor, 4 (3-5.25) and arterial blood gas machine, 0(0-1). The anaesthetists led in running 90% of the units. CONCLUSION This survey showed a low ICU bed capacity and deficits in basic and advanced haemodynamic monitoring equipment. There is also shortage of trained ICU Physicians.
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Affiliation(s)
- Obashina Ogunbiyi
- Intensive and Critical Care Society of Nigeria, c/o Department of Anaesthesia, Lagos University Teaching Hospital, Idi-Araba, Lagos State, Nigeria
| | - Arinola Sanusi
- Department of Anaesthesia, University of Ibadan/University College Hospital, Ibadan, Oyo State, Nigeria
| | - Babatunde Osinaike
- Department of Anaesthesia, University of Ibadan/University College Hospital, Ibadan, Oyo State, Nigeria.
| | - Saidu Yakubu
- Department of Anaesthesia, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Nigeria
| | - Muyiwa Rotimi
- Department of Anaesthesia, Lagos University Teaching Hospital, Idi-Araba, Lagos State, Nigeria
| | - Oluwabunmi Fatungase
- Department of Anaesthesia, Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun State, Nigeria
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Abstract
OBJECTIVE Embedding researchers within health systems results in more socially relevant research and more effective uptake of evidence into policy and practice. However, the practice of embedded health service research remains poorly understood. We explored and assessed the development of embedded participatory approaches to health service research by a health research team in Kenya highlighting the different ways multiple stakeholders were engaged in a neonatal research study. METHODS We conducted semistructured qualitative interviews with key stakeholders. Data were analysed thematically using both inductive and deductive approaches. SETTING Over recent years, the Health Services Unit within the Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme in Nairobi Kenya, has been working closely with organisations and technical stakeholders including, but not limited to, medical and nursing schools, frontline health workers, senior paediatricians, policymakers and county officials, in developing and conducting embedded health research. This involves researchers embedding themselves in the contexts in which they carry out their research (mainly in county hospitals, local universities and other training institutions), creating and sustaining social networks. Researchers collaboratively worked with stakeholders to identify clinical, operational and behavioural issues related to routine service delivery, formulating and exploring research questions to bring change in practice PARTICIPANTS: We purposively selected 14 relevant stakeholders spanning policy, training institutions, healthcare workers, regulatory councils and professional associations. RESULTS The value of embeddedness is highlighted through the description of a recently completed project, Health Services that Deliver for Newborns (HSD-N). We describe how the HSD-N research process contributed to and further strengthened a collaborative research platform and illustrating this project's role in identifying and generating ideas about how to tackle health service delivery problems CONCLUSIONS: We conclude with a discussion about the experiences, challenges and lessons learned regarding engaging stakeholders in the coproduction of research.
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Affiliation(s)
- Jacinta Nzinga
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - Caroline Jones
- Health Systems Research and Ethics, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, Oxford University, Oxford, UK
| | - David Gathara
- Health Systems Research and Ethics, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Mike English
- Health Systems Research and Ethics, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, Oxford University, Oxford, UK
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Kumar H, Bhat AA, Alwadhi V, Khanna R, Neogi SB, Khera A, Deb S. Situational Analysis of Management of Childhood Diarrhea and Pneumonia in 13 District Hospitals in India. Indian Pediatr 2021. [PMID: 33408280 PMCID: PMC8079854 DOI: 10.1007/s13312-021-2191-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Objective To generate evidence on the current situation of hospital care (emergency, inpatient and outpatient), for managing children presenting with diarrhea and pneumonia at 13 district hospitals in India. Design Facility-based assessment of district hospitals. Settings 13 district hospitals in four states of Bihar, Madhya Pradesh, Odisha and Rajasthan. Participants Staff nurses and doctors. Intervention None. Methods An assessment was done across 13 district hospitals in four states by a group or trained assessors using an adapted quality assurance tool developed by Government of India where each aspect of care was scored (maximum score 5). Emergency services and triage, case management practices, laboratory support, and record maintenance for diarrhea and pneumonia were assessed. Results Separate diarrhea treatment unit was not earmarked in any of the DHs surveyed. Overall score obtained for adequate management of diarrhea and pneumonia was 2 and 2.2 which were poor. Pediatric beds were 6.8% of the total bed strength against the recommended 8–10%. There was a 65 percent shortfall in the numbers of medical officers in position and 48 percent shortfall of nurses. There were issues with availability and utilization of drugs and equipment at appropriate places with cumulative score of 2.8. Triage for sick children was absent in all the facilities. Conclusion The standards of pediatric care for management of diarrhea and pneumonia were far from satisfactory. This calls for improvement of pediatric care units and implementation of operational guidelines for improving management of diarrhea and pneumonia.
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Vincent CA, Mboga M, Gathara D, Were F, Amalberti R, English M. How to do no harm: empowering local leaders to make care safer in low-resource settings. Arch Dis Child 2021; 106:333-337. [PMID: 33574028 PMCID: PMC7982924 DOI: 10.1136/archdischild-2020-320631] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 09/27/2020] [Accepted: 01/24/2021] [Indexed: 11/05/2022]
Abstract
In a companion paper, we showed how local hospital leaders could assess systems and identify key safety concerns and targets for system improvement. In the present paper, we consider how these leaders might implement practical, low-cost interventions to improve safety. Our focus is on making immediate safety improvements both to directly improve patient care and as a foundation for advancing care in the longer-term. We describe a 'portfolio' approach to safety improvement in four broad categories: prioritising critical processes, such as checking drug doses; strengthening the overall system of care, for example, by introducing multiprofessional handovers; control of known risks, such as only using continuous positive airway pressure when appropriate conditions are met; and enhancing detection and response to hazardous situations, such as introducing brief team meetings to identify and respond to immediate threats and challenges. Local clinical leaders and managers face numerous challenges in delivering safe care but, if given sufficient support, they are nevertheless in a position to bring about major improvements. Skills in improving safety and quality should be recognised as equivalent to any other form of (sub)specialty training and as an essential element of any senior clinical or management role. National professional organisations need to promote appropriate education and provide coaching, mentorship and support to local leaders.
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Affiliation(s)
| | | | - David Gathara
- Health Services Unit, KEMRI-Wellcome Trust, Nairobi, Kenya,London School of Hygiene & Tropical Medicine, London, UK
| | - Fred Were
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Rene Amalberti
- Foundation for an Industrial Safety Culture, Toulouse, France
| | - Mike English
- Health Services Unit, KEMRI-Wellcome Trust, Nairobi, Kenya .,Oxford Centre for Global Health Research, Nuffiled Department of Medicine, University of Oxford, Oxford, UK
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English M, Irimu G, Akech S, Aluvaala J, Ogero M, Isaaka L, Malla L, Tuti T, Gathara D, Oliwa J, Agweyu A. Employing learning health system principles to advance research on severe neonatal and paediatric illness in Kenya. BMJ Glob Health 2021; 6:e005300. [PMID: 33758014 PMCID: PMC7993294 DOI: 10.1136/bmjgh-2021-005300] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/03/2021] [Accepted: 03/07/2021] [Indexed: 11/03/2022] Open
Abstract
We have worked to develop a Clinical Information Network (CIN) in Kenya as an early form of learning health systems (LHS) focused on paediatric and neonatal care that now spans 22 hospitals. CIN's aim was to examine important outcomes of hospitalisation at scale, identify and ultimately solve practical problems of service delivery, drive improvements in quality and test interventions. By including multiple routine settings in research, we aimed to promote generalisability of findings and demonstrate potential efficiencies derived from LHS. We illustrate the nature and range of research CIN has supported over the past 7 years as a form of LHS. Clinically, this has largely focused on common, serious paediatric illnesses such as pneumonia, malaria and diarrhoea with dehydration with recent extensions to neonatal illnesses. CIN also enables examination of the quality of care, for example that provided to children with severe malnutrition and the challenges encountered in routine settings in adopting simple technologies (pulse oximetry) and more advanced diagnostics (eg, Xpert MTB/RIF). Although regular feedback to hospitals has been associated with some improvements in quality data continue to highlight system challenges that undermine provision of basic, quality care (eg, poor access to blood glucose testing and routine microbiology). These challenges include those associated with increased mortality risk (eg, delays in blood transfusion). Using the same data the CIN platform has enabled conduct of randomised trials and supports malaria vaccine and most recently COVID-19 surveillance. Employing LHS principles has meant engaging front-line workers, clinical managers and national stakeholders throughout. Our experience suggests LHS can be developed in low and middle-income countries that efficiently enable contextually appropriate research and contribute to strengthening of health services and research systems.
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Affiliation(s)
- Mike English
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
- Oxford Centre for Global Health Research, Nuffield Department of Clinical Medicine, Oxford, UK
| | - Grace Irimu
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Samuel Akech
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - Jalemba Aluvaala
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Morris Ogero
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - Lynda Isaaka
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - Lucas Malla
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - Timothy Tuti
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - David Gathara
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - Jacquie Oliwa
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Ambrose Agweyu
- Epidemiology and Demography, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
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English M, Nzinga J, Irimu G, Gathara D, Aluvaala J, McKnight J, Wong G, Molyneux S. Programme theory and linked intervention strategy for large-scale change to improve hospital care in a low and middle-income country - A Study Pre-Protocol. Wellcome Open Res 2020; 5:265. [PMID: 33274301 PMCID: PMC7684682 DOI: 10.12688/wellcomeopenres.16379.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2020] [Indexed: 12/24/2023] Open
Abstract
In low and middle-income countries (LMIC) general hospitals are important for delivering some key acute care services. Neonatal care is emblematic of these acute services as averting deaths requires skilled care over many days from multiple professionals with at least basic equipment. However, hospital care is often of poor quality and large-scale change is needed to improve outcomes. In this manuscript we aim to show how we have drawn upon our understanding of contexts of care in Kenyan general hospital NBUs, and on social and behavioural theories that offer potential mechanisms of change in these settings, to develop an initial programme theory guiding a large scale change intervention to improve neonatal care and outcomes. Our programme theory is an expression of our assumptions about what actions will be both useful and feasible. It incorporates a recognition of our strengths and limitations as a research-practitioner partnership to influence change. The steps we employ represent the initial programme theory development phase commonly undertaken in many Realist Evaluations. However, unlike many Realist Evaluations that develop initial programme theories focused on pre-existing interventions or programmes, our programme theory informs the design of a new intervention that we plan to execute. Within this paper we articulate briefly how we propose to operationalise this new intervention. Finally, we outline the quantitative and qualitative research activities that we will use to address specific questions related to the delivery and effects of this new intervention, discussing some of the challenges of such study designs. We intend that this research on the intervention will inform future efforts to revise the programme theory and yield transferable learning.
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Affiliation(s)
- Mike English
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Jacinta Nzinga
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | - Grace Irimu
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | - David Gathara
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | | | - Jacob McKnight
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Geoffrey Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sassy Molyneux
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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English M, Nzinga J, Irimu G, Gathara D, Aluvaala J, McKnight J, Wong G, Molyneux S. Programme theory and linked intervention strategy for large-scale change to improve hospital care in a low and middle-income country - A Study Pre-Protocol. Wellcome Open Res 2020; 5:265. [PMID: 33274301 PMCID: PMC7684682 DOI: 10.12688/wellcomeopenres.16379.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2020] [Indexed: 01/25/2023] Open
Abstract
In low and middle-income countries (LMIC) general hospitals are important for delivering some key acute care services. Neonatal care is emblematic of these acute services as averting deaths requires skilled care over many days from multiple professionals with at least basic equipment. However, hospital care is often of poor quality and large-scale change is needed to improve outcomes. In this manuscript we aim to show how we have drawn upon our understanding of contexts of care in Kenyan general hospital NBUs, and on social and behavioural theories that offer potential mechanisms of change in these settings, to develop an initial programme theory guiding a large scale change intervention to improve neonatal care and outcomes. Our programme theory is an expression of our assumptions about what actions will be both useful and feasible. It incorporates a recognition of our strengths and limitations as a research-practitioner partnership to influence change. The steps we employ represent the initial programme theory development phase commonly undertaken in many Realist Evaluations. However, unlike many Realist Evaluations that develop initial programme theories focused on pre-existing interventions or programmes, our programme theory informs the design of a new intervention that we plan to execute. Within this paper we articulate briefly how we propose to operationalise this new intervention. Finally, we outline the quantitative and qualitative research activities that we will use to address specific questions related to the delivery and effects of this new intervention, discussing some of the challenges of such study designs. We intend that this research on the intervention will inform future efforts to revise the programme theory and yield transferable learning.
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Affiliation(s)
- Mike English
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Jacinta Nzinga
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | - Grace Irimu
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | - David Gathara
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | | | - Jacob McKnight
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Geoffrey Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sassy Molyneux
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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Sirijatuphat R, Nookeu P, Thamlikitkul V. Effectiveness of Implementing a Locally Developed Antibiotic Use Guideline for Community-Acquired Cellulitis at a Large Tertiary Care University Hospital in Thailand. Open Forum Infect Dis 2020; 7:ofaa411. [PMID: 33134410 PMCID: PMC7585325 DOI: 10.1093/ofid/ofaa411] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 09/02/2020] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
To determine the effectiveness of implementing a locally developed clinical practice guideline (CPG) for antibiotic treatment in adults with community-acquired cellulitis at Siriraj Hospital in Bangkok, Thailand.
Methods
The CPG for antibiotic treatment of community-acquired cellulitis was developed based on local data during June to December 2016. The CPG was introduced by multifaceted interventions, including posters, brochures, circular letters, social media, conference, classroom training, and interactive education during January to September 2018.
Results
Among 360 patients with community-acquired cellulitis, 84.4% were ambulatory and 15.6% were hospitalized. The median age of patients was 62 years, and 59.4% were female. Antibiotic prescription according to CPG (CPG-compliant group) was observed in 251 patients (69.7%), and CPG noncompliance was found in 109 patients (30.3%) (CPG-noncompliant group). The demographics and characteristics of patients were comparable between groups. Patients in the CPG-compliant group had a significantly lower rate of intravenous antibiotics (18.7% vs 33.9%, P = .007), lower prescription rate of broad-spectrum antibiotics (14.7% vs 78.9%, P < .001) and antibiotic combination (6.4% vs 13.8%, P = .022), shorter median duration of antibiotic treatment (7 vs 10 days, P < .001), lower median cost of antibiotic treatment (US $3 vs $7, P < .001), and lower median hospitalization cost (US $601 vs $1587, P = .008) than those in the CPG-noncompliant group. Treatment outcomes were not significantly different between groups.
Conclusions
Adherence to CPG seems to reduce inappropriate prescription of broad-spectrum antibiotic or antibiotic combination and treatment costs in adults with community-acquired cellulitis without differences in favorable outcomes or adverse events.
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Affiliation(s)
- Rujipas Sirijatuphat
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pornboonya Nookeu
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Visanu Thamlikitkul
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Hands S, Verriotis M, Mustapha A, Ragab H, Hands C. Nurse-led implementation of ETAT+ is associated with reduced mortality in a children's hospital in Freetown, Sierra Leone. Paediatr Int Child Health 2020; 40:186-193. [PMID: 31967527 DOI: 10.1080/20469047.2020.1713610] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND In the wake of the Ebola virus disease (EVD) epidemic in Sierra Leone, secondary care facilities faced an increase in admissions with few members of medical staff available to assess and treat patients. This led to long waiting times in hospital outpatient departments. The study was undertaken in the outpatient department of Ola During Children's Hospital (the tertiary paediatric hospital for Sierra Leone) in the period immediately following the EVD epidemic of 2014-2015. AIMS This retrospective analysis of operational programme data aimed to assess whether a quality-improvement approach and task-sharing between medical and nursing staff improved the quality of triage and the timeliness of care. METHODS All staff working in the outpatient department were offered a 4-week training course, followed by on-the-job supervision and support for 6 months. Nurses who successfully completed the course were given responsibility for the initial assessment of sick patients and for prescribing and giving initial treatment. Data were collected at three points: before intervention and at 3 and 6 months after initiation of the intervention. All children presenting to the hospital for medical attention between 0800 and 1400 Monday to Friday were included. Triage assessment by the outpatient nurse was compared to that made by a clinically experienced observer, and the time taken for each child to be triaged, assessed and given initial treatment was recorded. RESULTS Between months 0 and 6 of the intervention, detection of emergency signs by the triage nurse improved from 30% to 100%, and detection of priority signs improved from 34% to 100%. For children presenting with emergency signs, the median time between triage and full assessment improved from 57 minutes before intervention to 17 minutes at 3 months and 5 minutes at 6 months (p < 0.0005). For the same group, median time between triage and first antibiotic or antimalarial treatment improved from 220 minutes before intervention to 40 minutes at 3 months and 18 minutes at 6 months (p = 0.006). CONCLUSION The results indicate that, with appropriate training and support, extending the emergency assessment and treatment of sick children to nursing staff in West African hospitals may improve the accuracy of triage and the time to assessment and treatment of children presenting with signs of serious illness.
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Affiliation(s)
- Sandra Hands
- Global Team, Royal College of Paediatrics and Child Health , London, UK
| | - Madeleine Verriotis
- Developmental Neurosciences Programme, UCL GOS Institute of Child Health , London, UK
| | | | - Hany Ragab
- Global Team, Royal College of Paediatrics and Child Health , London, UK
| | - Christopher Hands
- Global Team, Royal College of Paediatrics and Child Health , London, UK
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Mpimbaza A, Walemwa R, Kapisi J, Sserwanga A, Namuganga JF, Kisambira Y, Tagoola A, Nanteza JF, Rutazaana D, Staedke SG, Dorsey G, Opigo J, Kamau A, Snow RW. The age-specific incidence of hospitalized paediatric malaria in Uganda. BMC Infect Dis 2020; 20:503. [PMID: 32660434 PMCID: PMC7359223 DOI: 10.1186/s12879-020-05215-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 07/01/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Understanding the relationship between malaria infection risk and disease outcomes represents a fundamental component of morbidity and mortality burden estimations. Contemporary data on severe malaria risks among populations of different parasite exposures are scarce. Using surveillance data, we compared rates of paediatric malaria hospitalisation in areas of varying parasite exposure levels. METHODS Surveillance data at five public hospitals; Jinja, Mubende, Kabale, Tororo, and Apac were assembled among admissions aged 1 month to 14 years between 2017 and 2018. The address of each admission was used to define a local catchment population where national census data was used to define person-year-exposure to risk. Within each catchment, historical infection prevalence was assembled from previously published data and current infection prevalence defined using 33 population-based school surveys among 3400 children. Poisson regression was used to compute the overall and site-specific incidences with 95% confidence intervals. RESULTS Both current and historical Plasmodium falciparum prevalence varied across the five sites. Current prevalence ranged from < 1% in Kabale to 54% in Apac. Overall, the malaria admission incidence rate (IR) was 7.3 per 1000 person years among children aged 1 month to 14 years of age (95% CI: 7.0, 7.7). The lowest rate was described at Kabale (IR = 0.3; 95 CI: 0.1, 0.6) and highest at Apac (IR = 20.3; 95 CI: 18.9, 21.8). There was a correlation between IR across the five sites and the current parasite prevalence in school children, though findings were not statistically significant. Across all sites, except Kabale, malaria admissions were concentrated among young children, 74% were under 5 years. The median age of malaria admissions at Kabale hospital was 40 months (IQR 20, 72), and at Apac hospital was 36 months (IQR 18, 69). Overall, severe anaemia (7.6%) was the most common presentation and unconsciousness (1.8%) the least common. CONCLUSION Malaria hospitalisation rates remain high in Uganda particularly among young children. The incidence of hospitalized malaria in different locations in Uganda appears to be influenced by past parasite exposure, immune acquisition, and current risks of infection. Interruption of transmission through vector control could influence age-specific severe malaria risk.
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Affiliation(s)
- Arthur Mpimbaza
- Child Health and Development Centre, College of Health Sciences, Makerere University, Kampala, Uganda.
- Infectious Diseases Research Collaboration, Kampala, Uganda.
| | - Richard Walemwa
- Department of Prevention, Care and Treatment, Infectious Diseases Institute, Kampala, Uganda
| | - James Kapisi
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | | | | | - Abner Tagoola
- Jinja Regional Referral, Hospital, Republic of Uganda Ministry of Health, Jinja, Uganda
| | - Jane Frances Nanteza
- Mubende Regional Referral, Hospital, Republic of Uganda Ministry of Health, Mubende, Uganda
| | - Damain Rutazaana
- National Malaria Control Program, Ministry of Health Uganda, Kampala, Uganda
| | | | - Grant Dorsey
- Department of Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, USA
| | - Jimmy Opigo
- National Malaria Control Program, Ministry of Health Uganda, Kampala, Uganda
| | - Alice Kamau
- Population Health Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Robert W Snow
- Population Health Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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Tuti T, Winters N, Edgcombe H, Muinga N, Wanyama C, English M, Paton C. Evaluation of Adaptive Feedback in a Smartphone-Based Game on Health Care Providers' Learning Gain: Randomized Controlled Trial. J Med Internet Res 2020; 22:e17100. [PMID: 32628115 PMCID: PMC7380991 DOI: 10.2196/17100] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 03/13/2020] [Accepted: 04/08/2020] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Although smartphone-based emergency care training is more affordable than traditional avenues of training, it is still in its infancy, remains poorly implemented, and its current implementation modes tend to be invariant to the evolving learning needs of the intended users. In resource-limited settings, the use of such platforms coupled with gamified approaches remains largely unexplored, despite the lack of traditional training opportunities, and high mortality rates in these settings. OBJECTIVE The primary aim of this randomized experiment is to determine the effectiveness of offering adaptive versus standard feedback, on the learning gains of clinicians, through the use of a smartphone-based game that assessed their management of a simulated medical emergency. A secondary aim is to examine the effects of learner characteristics and learning spacing with repeated use of the game on the secondary outcome of individualized normalized learning gain. METHODS The experiment is aimed at clinicians who provide bedside neonatal care in low-income settings. Data were captured through an Android app installed on the study participants' personal phones. The intervention, which was based on successful attempts at a learning task, included adaptive feedback provided within the app to the experimental arm, whereas the control arm received standardized feedback. The primary end point was completion of the second learning session. Of the 572 participants enrolled between February 2019 and July 2019, 247 (43.2%) reached the primary end point. The primary outcome was standardized relative change in learning gains between the study arms as measured by the Morris G effect size. The secondary outcomes were the participants individualized normalized learning gains. RESULTS The effect of adaptive feedback on care providers' learning gain was found to be g=0.09 (95% CI -0.31 to 0.46; P=.47). In exploratory analysis, using normalized learning gains, when subject-treatment interaction and differential time effect was controlled for, this effect increased significantly to 0.644 (95% CI 0.35 to 0.94; P<.001) with immediate repetition, which is a moderate learning effect, but reduced significantly by 0.28 after a week. The overall learning change from the app use in both arms was large and may have obscured a direct effect of feedback. CONCLUSIONS There is a considerable learning gain between the first two rounds of learning with both forms of feedback and a small added benefit of adaptive feedback after controlling for learner differences. We suggest that linking the adaptive feedback provided to care providers to how they space their repeat learning session(s) may yield higher learning gains. Future work might explore in more depth the feedback content, in particular whether or not explanatory feedback (why answers were wrong) enhances learning more than reflective feedback (information about what the right answers are). TRIAL REGISTRATION Pan African Clinical Trial Registry (PACTR) 201901783811130; https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=5836. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.2196/13034.
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Affiliation(s)
- Timothy Tuti
- Kellogg College, University of Oxford, Oxford, United Kingdom.,KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.,Department of Education, University of Oxford, Oxford, United Kingdom
| | - Niall Winters
- Kellogg College, University of Oxford, Oxford, United Kingdom.,Department of Education, University of Oxford, Oxford, United Kingdom
| | - Hilary Edgcombe
- Nuffield Division of Anaesthetics, University of Oxford, Oxford, United Kingdom
| | - Naomi Muinga
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | - Mike English
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.,Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Chris Paton
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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Ogero M, Akech S, Malla L, Agweyu A, Irimu G, English M. Examining which clinicians provide admission hospital care in a high mortality setting and their adherence to guidelines: an observational study in 13 hospitals. Arch Dis Child 2020; 105:648-654. [PMID: 32169853 PMCID: PMC7361020 DOI: 10.1136/archdischild-2019-317256] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 12/23/2019] [Accepted: 01/03/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND We explored who actually provides most admission care in hospitals offering supervised experiential training to graduating clinicians in a high mortality setting where practices deviate from guideline recommendations. METHODS We used a large observational data set from 13 Kenyan county hospitals from November 2015 through November 2018 where patients were linked to admitting clinicians. We explored guideline adherence after creating a cumulative correctness of Paediatric Admission Quality of Care (cPAQC) score on a 5-point scale (0-4) in which points represent correct, sequential progress in providing care perfectly adherent to guidelines comprising admission assessment, diagnosis and treatment. At the point where guideline adherence declined the most we dichotomised the cPAQC score and used multilevel logistic regression models to explore whether clinician and patient-level factors influence adherence. RESULTS There were 1489 clinicians who could be linked to 53 003 patients over a period of 3 years. Patients were rarely admitted by fully qualified clinicians and predominantly by preregistration medical officer interns (MOI, 46%) and diploma level clinical officer interns (COI, 41%) with a median of 28 MOI (range 11-68) and 52 COI (range 5-160) offering care per study hospital. The cPAQC scores suggest that perfect guideline adherence is found in ≤12% of children with malaria, pneumonia or diarrhoea with dehydration. MOIs were more adherent to guidelines than COI (adjusted OR 1.19 (95% CI 1.07 to 1.34)) but multimorbidity was significantly associated with lower guideline adherence. CONCLUSION Over 85% of admissions to hospitals in high mortality settings that offer experiential training in Kenya are conducted by preregistration clinicians. Clinical assessment is good but classifying severity of illness in accordance with guideline recommendations is a challenge. Adherence by MOI with 6 years' training is better than COI with 3 years' training, performance does not seem to improve during their 3 months of paediatric rotations.
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Affiliation(s)
- Morris Ogero
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- School of Mathematics, University of Nairobi College of Biological and Physical Sciences, Nairobi, Kenya
| | - Samuel Akech
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Lucas Malla
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Ambrose Agweyu
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Grace Irimu
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Pediatrics, University of Nairobi, Nairobi, Kenya
| | - Mike English
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Lazzerini M, Wanzira H, Lochoro P, Ndunguste A, Ictho J, Katungi A, Mariani I, Putoto G. Quality of healthcare for children with severe acute malnutrition in a refugee setting: cross-sectional study in West Nile Region, Uganda. BMJ Open 2020; 10:e034738. [PMID: 32532769 PMCID: PMC7295434 DOI: 10.1136/bmjopen-2019-034738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES 5.0 million annual deaths in low-income and middle-income countries are due to poor quality of care (QOC). We evaluated the QOC provided to malnourished children in West Nile Region in Uganda. DESIGN Cross-sectional study. SETTING West Nile Region, an area hosting over one million refugees. PARTICIPANTS Among 148 facilities providing nutritional services, 30 randomly selected facilities (20%) and the records of 1467 children with severe acute malnutrition (100% of those attending the 30 facilities during last year) were assessed. OUTCOMES The national Nutrition Service Delivery Assessment (NSDA) tool was used to assess capacity areas related to QOC. Case management, data quality and health outcomes were assessed from official health records. Multivariate analysis was performed to explore factors significantly associated with better cure rates. RESULTS Of 305 NSDA scores allocated to 30 participating centres, 201 (65.9%) were 'good' or 'excellent'. However, 20 (66.7%) facilities had 'poor' 'quality improvement mechanisms' and 13 (43.3%) had 'poor' 'human resources'. Overall data quality in official records was poor, while recorded quality of case management was overall fair. Average cure rate was significantly lower than international Sphere standards (50.4% vs 75% p<0.001) with a higher default rate (23.2% vs 15% p<0.001). Large heterogeneity among facilities was detected for all indicators. Refugee-hosting and non-refugee-hosting facilities had a similar cure rate (47.1% vs 52.1%) though transfer rates were higher for those hosting refugees (21.5% vs 1.9%, p<0.001) despite better 'equipment and supplies'. 'Good/excellent' 'equipment' and 'store management' were significantly associated with better cure rates in outpatient therapeutic centres (+55.9, p<0.001; +65.4, p=0.041, respectively) in multivariate analysis. CONCLUSIONS Though most NSDA capacity areas were rated good or excellent, health outcomes of malnourished children in West Nile Region, both in refugee-hosting and non-refugee-hosting facilities, are significantly below international standards. Effective and sustainable approaches to improve malnourished child health outcomes are needed.
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Affiliation(s)
- Marzia Lazzerini
- WHO Collaborating Center, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, Trieste, Italy
| | - Humphrey Wanzira
- WHO Collaborating Center, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, Trieste, Italy
| | | | - Amos Ndunguste
- Former Nutrition Advisor, Doctors with Africa, CUAMM, Kampala, Uganda
| | | | | | - Ilaria Mariani
- WHO Collaborating Center, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, Trieste, Italy
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Weir A, Kitto S, Smith J, Presseau J, Colman I, Hatcher S. Barriers and enablers to conducting cluster randomized control trials in hospitals: A theory-informed scoping review. Eval Program Plann 2020; 80:101815. [PMID: 32146300 DOI: 10.1016/j.evalprogplan.2020.101815] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 02/01/2020] [Accepted: 02/29/2020] [Indexed: 06/10/2023]
Abstract
BACKGROUND Cluster randomized control trials (cRCTs) have unique challenges compared to single site trials with regards to conduct of the trial, and it is important to understand these barriers. The aim of this scoping review was to describe the current literature surrounding the implementation of the cRCTs in hospitals. METHODS The search strategy was designed to identify literature relevant to conduct of cRCTs, with hospitals as the unit of randomization. Data was extracted and was mapped using the Consolidated Framework for Implementation Research (CFIR) as a codebook, which contains 39 constructs organized into five domains. RESULTS Twenty-two articles met inclusion criteria and were included. 18 of 39 constructs of the CFIR were identified in coding, spanning four of the five domains. Barriers to the conduct of the trial were rarely reported as the main outcome of the study, and few details were included in the identified literature. CONCLUSIONS The review can provide guidance to future researchers planning cRCTs in hospitals. It also identified a large gap in reporting of conduct of these trials, demonstrating the need for a research agenda that further explores the barriers and facilitators, with the aim of garnering knowledge for improved guidance in the implementation.
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Affiliation(s)
- Arielle Weir
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, K1G 5Z3, Canada.
| | - Simon Kitto
- Department of Innovation in Medical Education, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, K1H 8M5, Canada
| | - Jennifer Smith
- Population Health, Interdisciplinary School of Health Sciences, University of Ottawa, Ottawa, Ontario, K1N 7K4, Canada
| | - Justin Presseau
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, K1G 5Z3, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, K1H 8L6, Canada
| | - Ian Colman
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, K1G 5Z3, Canada
| | - Simon Hatcher
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, K1G 5Z3, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, K1H 8L6, Canada
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Hvarfner A, Blixt J, Schell CO, Castegren M, Lugazia ER, Mulungu M, Litorp H, Baker T. Vital Signs Directed Therapy for the Critically Ill: Improved Adherence to the Treatment Protocol Two Years after Implementation in an Intensive Care Unit in Tanzania. Emerg Med Int 2020; 2020:4819805. [PMID: 32377435 DOI: 10.1155/2020/4819805] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 11/30/2019] [Indexed: 12/23/2022] Open
Abstract
Treating deranged vital signs is a mainstay of critical care throughout the world. In an ICU in a university hospital in Tanzania, the implementation of the Vital Signs Directed Therapy Protocol in 2014 led to an increase in acute treatments for deranged vital signs. The mortality rate for hypotensive patients decreased from 92% to 69%. In this study, the aim was to investigate the sustainability of the implementation two years later. An observational, patient-record-based study was conducted in the ICU in August 2016. Data on deranged vital signs and acute treatments were extracted from the patients' charts. Adherence to the protocol, defined as an acute treatment in the same or subsequent hour following a deranged vital sign, was calculated and compared with before and immediately after implementation. Two-hundred and eighty-nine deranged vital signs were included. Adherence was 29.8% two years after implementation, compared with 16.6% (p < 0.001) immediately after implementation and 2.9% (p < 0.001) before implementation. Consequently, the implementation of the Vital Signs Directed Therapy Protocol appears to have led to a sustainable increase in the treatment of deranged vital signs. The protocol may have potential to improve patient safety in other settings where critically ill patients are managed.
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Malla L, Perera-Salazar R, Akech S, Ogero M, Julius T, Irimu G, English M. Examining the effectiveness of zinc treatment in children admitted with diarrhoea in Kenya's public hospitals: an observational comparative effectiveness study. J Glob Health 2019; 9:020416. [PMID: 31555441 PMCID: PMC6748787 DOI: 10.7189/jogh.09.020416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Kenyan paediatric treatment protocols recommend the use of zinc supplement for all children with diarrhoea. However, there is limited evidence of benefit for young children aged 1-5 months and those who are well-nourished. We examine effectiveness of zinc supplementation for children admitted with diarrhoea to Kenya’s public hospitals with different nutritional and age categories. This is to determine whether the current policy where zinc is prescribed for all children with diarrhoea is appropriate. Methods We explore the effect of zinc treatment on time to discharge for children aged 1-5 and 6-59 months and amongst those classified as either severely – moderately under-nourished or well-nourished. To overcome the challenges associated with non-random allocation of treatments and missing data in these observational data, we use propensity score methods and multiple imputation to minimize bias. Results The analysis included 1645 (1-5 months) and 11 546 (6-59 months) children respectively. The estimated sub-distribution hazard ratios for being discharged in the zinc group vs the non-zinc group were 1.25 (95% confidence interval (CI) = 1.07, 1.46) and 1.17 (95% CI = 1.10, 1.24) in these respective age categories. Zinc treatment was associated with shorter time to discharge in both well and under-nourished children. Conclusion Zinc treatment, in general, was associated with shorter time to discharge. In the absence of significant adverse effects, these data support the continued use of zinc for admissions with diarrhoea including those aged 1-5 months and in those who are well-nourished.
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Affiliation(s)
- Lucas Malla
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Rafael Perera-Salazar
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Samuel Akech
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Morris Ogero
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Thomas Julius
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Grace Irimu
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Mike English
- Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
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Gachau S, Owuor N, Njagi EN, Ayieko P, English M. Analysis of Hierarchical Routine Data With Covariate Missingness: Effects of Audit & Feedback on Clinicians' Prescribed Pediatric Pneumonia Care in Kenyan Hospitals. Front Public Health 2019; 7:198. [PMID: 31380338 PMCID: PMC6646705 DOI: 10.3389/fpubh.2019.00198] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Accepted: 07/02/2019] [Indexed: 12/22/2022] Open
Abstract
Background: Routine clinical data are widely used in many countries to monitor quality of care. A limitation of routine data is missing information which occurs due to lack of documentation of care processes by health care providers, poor record keeping, or limited health care technology at facility level. Our objective was to address missing covariates while properly accounting for hierarchical structure in routine pediatric pneumonia care. Methods: We analyzed routine data collected during a cluster randomized trial to investigating the effect of audit and feedback (A&F) over time on inpatient pneumonia care among children admitted in 12 Kenyan hospitals between March and November 2016. Six hospitals in the intervention arm received enhance A&F on classification and treatment of pneumonia cases in addition to a standard A&F report on general inpatient pediatric care. The remaining six in control arm received standard A&F alone. We derived and analyzed a composite outcome known as Pediatric Admission Quality of Care (PAQC) score. In our analysis, we adjusted for patients, clinician and hospital level factors. Missing data occurred in patient and clinician level variables. We did multiple imputation of missing covariates within the joint model imputation framework. We fitted proportion odds random effects model and generalized estimating equation (GEE) models to the data before and after multilevel multiple imputation. Results: Overall, 2,299 children aged 2 to 59 months were admitted with childhood pneumonia in 12 hospitals during the trial period. 2,127 (92%) of the children (level 1) were admitted by 378 clinicians across the 12 hospitals. Enhanced A&F led to improved inpatient pediatric pneumonia care over time compared to standard A&F. Female clinicians and hospitals with low admission workload were associated with higher uptake of the new pneumonia guidelines during the trial period. In both random effects and marginal model, parameter estimates were biased and inefficient under complete case analysis. Conclusions: Enhanced A&F improved the uptake of WHO recommended pediatric pneumonia guidelines over time compared to standard audit and feedback. When imputing missing data, it is important to account for the hierarchical structure to ensure compatibility with analysis models of interest to alleviate bias.
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Affiliation(s)
- Susan Gachau
- Health Services Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya.,School of Mathematics, University of Nairobi, Nairobi, Kenya
| | - Nelson Owuor
- School of Mathematics, University of Nairobi, Nairobi, Kenya
| | - Edmund Njeru Njagi
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Philip Ayieko
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Mike English
- Health Services Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya.,Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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Tuti T, Winters N, Muinga N, Wanyama C, English M, Paton C. Evaluation of Adaptive Feedback in a Smartphone-Based Serious Game on Health Care Providers' Knowledge Gain in Neonatal Emergency Care: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2019; 8:e13034. [PMID: 31350837 PMCID: PMC6688438 DOI: 10.2196/13034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 05/10/2019] [Accepted: 06/17/2019] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Although smartphone-based clinical training to support emergency care training is more affordable than traditional avenues of training, it is still in its infancy and remains poorly implemented. In addition, its current implementations tend to be invariant to the evolving learning needs of the intended users. In resource-limited settings, the use of such platforms coupled with serious-gaming approaches remain largely unexplored and underdeveloped, even though they offer promise in terms of addressing the health workforce skill imbalance and lack of training opportunities associated with the high neonatal mortality rates in these settings. OBJECTIVE This randomized controlled study aims to assess the effectiveness of offering adaptive versus standard feedback through a smartphone-based serious game on health care providers' knowledge gain on the management of a neonatal medical emergency. METHODS The study is aimed at health care workers (physicians, nurses, and clinical officers) who provide bedside neonatal care in low-income settings. We will use data captured through an Android smartphone-based serious-game app that will be downloaded to personal phones belonging to the study participants. The intervention will be adaptive feedback provided within the app. The data captured will include the level of feedback provided to participants as they learn to use the mobile app, and performance data from attempts made during the assessment questions on interactive tasks participants perform as they progress through the app on emergency neonatal care delivery. The primary endpoint will be the first two complete rounds of learning within the app, from which the individuals' "learning gains" and Morris G intervention effect size will be computed. To minimize bias, participants will be assigned to an experimental or a control group by a within-app random generator, and this process will be concealed to both the study participants and the investigators until the primary endpoint is reached. RESULTS This project was funded in November 2016. It has been approved by the Central University Research Ethics Committee of the University of Oxford and the Scientific and Ethics Review Unit of the Kenya Medical Research Institute. Recruitment and data collection began from February 2019 and will continue up to July 31, 2019. As of July 18, 2019, we enrolled 541 participants, of whom 238 reached the primary endpoint, with a further 19 qualitative interviews conducted to support evaluation. Full analysis will be conducted once we reach the end of the study recruitment period. CONCLUSIONS This study will be used to explore the effectiveness of adaptive feedback in a smartphone-based serious game on health care providers in a low-income setting. This aspect of medical education is a largely unexplored topic in this context. In this randomized experiment, the risk of performance bias across arms is moderate, given that the active ingredient of the intervention (ie, knowledge) is a latent trait that is difficult to comprehensively control for in a real-world setting. However, the influence of any resulting bias that has the ability to alter the results will be assessed using alternative methods such as qualitative interviews. TRIAL REGISTRATION Pan African Clinical Trials Registry PACTR201901783811130; https://pactr.samrc.ac.za/TrialDisplay. aspx?TrialID=5836. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/13034.
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Affiliation(s)
- Timothy Tuti
- Department of Education, University of Oxford, Oxford, United Kingdom.,Kellogg College, University of Oxford, Oxford, United Kingdom.,KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Niall Winters
- Department of Education, University of Oxford, Oxford, United Kingdom.,Kellogg College, University of Oxford, Oxford, United Kingdom
| | - Naomi Muinga
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | - Mike English
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.,Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Chris Paton
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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Lazzerini M, Wanzira H, Lochoro P, Muyinda R, Segafredo G, Wamani H, Putoto G. Supportive supervision to improve the quality and outcome of outpatient care among malnourished children: a cluster randomised trial in Arua district, Uganda. BMJ Glob Health 2019; 4:e001339. [PMID: 31406583 PMCID: PMC6666809 DOI: 10.1136/bmjgh-2018-001339] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 05/08/2019] [Accepted: 05/11/2019] [Indexed: 11/17/2022] Open
Abstract
Introduction Suboptimal quality of paediatric care has been reported in resource-limited settings, but little evidence exists on interventions to improve it in such settings. This study aimed at testing supportive supervision (SS) for improving health status of malnourished children, quality of case management, overall quality of care, and the absolute number of children enrolled in the nutritional services. Methods This was a cluster randomised trial conducted in Arua district. Six health centres (HCs) with the highest volume of work were randomised to either SS or no intervention. SS was delivered by to HCs staff (phase 1), and later extended to community health workers (CHWs) (phase 2). The primary outcome was the cure rate, measured at children level. Quality of case management was assessed by six pre-defined indicators. Quality of care was assessed using the national Nutrition Service Delivery Assessment (NSDA) tool. Access to care was estimated with the number of children accessing HC nutritional services. Results Overall, 737 children were enrolled. In the intervention arm, the cure rate (83.8% vs 44.9%, risk ratio (RR)=1.91, 95% CI: 1.56–2.34, p=0.001), quality of care as scored by NSDA (RR=1.57, 95% CI: 1.01–2.44, p=0.035) and correctness in complementary treatment (RR=1.52, 95% CI: 1.40–1.67, p=0.001) were significantly higher compared with control. With the extension of SS to CHWs (phase 2), there was a significant 38.6% more children accessing care in the intervention HCs (RR=1.26, 95% CI: 1.11–1.44, p=0.001) compared with control. Conclusion SS significantly improved the cure rate of malnourished children, and the overall quality of care, SS to CHWs significantly increased the crude number of children enrolled in the nutritional services. More studies should confirm these results, and evaluate the cost-effectiveness of SS.
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Affiliation(s)
- Marzia Lazzerini
- WHO Collaborating Centre, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
| | - Humphrey Wanzira
- WHO Collaborating Centre, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
| | | | | | | | - Henry Wamani
- Department of Community Health and Behavioural Sciences, School of Public Health, Makerere University, Kampala, Uganda
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Tickell KD, Mangale DI, Tornberg-Belanger SN, Bourdon C, Thitiri J, Timbwa M, Njirammadzi J, Voskuijl W, Chisti MJ, Ahmed T, Shahid ASMSB, Diallo AH, Ouédrago I, Khan AF, Saleem AF, Arif F, Kazi Z, Mupere E, Mukisa J, Sukhtankar P, Berkley JA, Walson JL, Denno DM. A mixed method multi-country assessment of barriers to implementing pediatric inpatient care guidelines. PLoS One 2019; 14:e0212395. [PMID: 30908499 PMCID: PMC6433255 DOI: 10.1371/journal.pone.0212395] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 01/27/2019] [Indexed: 12/22/2022] Open
Abstract
Introduction Accelerating progress in reducing child deaths is needed in order to achieve the Sustainable Development Goal child mortality target. This will require a focus on vulnerable children–including young children, those who are undernourished or with acute illnesses requiring hospitalization. Improving adherence to inpatient guidelines may be an important strategy to reduce child mortality, including among the most vulnerable. The aim of our assessment of nine sub-Saharan African and South Asian hospitals was to determine adherence to pediatric inpatient care recommendations, in addition to capacity for and barriers to implementation of guideline-adherent care prior to commencing the Childhood Acute Illness and Nutrition (CHAIN) Cohort study. The CHAIN Cohort study aims to identify modifiable risk factors for poor inpatient and post discharge outcomes above and beyond implementation of guidelines. Methods Hospital infrastructure, staffing, durable equipment, and consumable supplies such as medicines and laboratory reagents, were evaluated through observation and key informant interviews. Inpatient medical records of 2–23 month old children were assessed for adherence to national and international guidelines. The records of children with severe acute malnutrition (SAM) were oversampled to reflect the CHAIN study population. Seven core adherence indicators were examined: oximetry and oxygen therapy, fluids, anemia diagnosis and transfusion, antibiotics, malaria testing and antimalarials, nutritional assessment and management, and HIV testing. Results All sites had facilities and equipment necessary to implement care consistent with World Health Organization and national guidelines. However, stockouts of essential medicines and laboratory reagents were reported to be common at some sites, even though they were mostly present during the assessment visits. Doctor and nurse to patient ratios varied widely. We reviewed the notes of 261 children with admission diagnoses of sepsis (17), malaria (47), pneumonia (70), diarrhea (106), and SAM (119); 115 had multiple diagnoses. Adherence to oxygen therapy, antimalarial, and malnutrition refeeding guidelines was >75%. Appropriate antimicrobials were prescribed for 75% of antibiotic-indicative conditions. However, 20/23 (87%) diarrhea and 20/27 (74%) malaria cases without a documented indication were prescribed antibiotics. Only 23/122 (19%) with hemoglobin levels meeting anemia criteria had recorded anemia diagnoses. HIV test results were infrequently documented even at hospitals with universal screening policies (66/173, 38%). Informants at all sites attributed inconsistent guideline implementation to inadequate staffing. Conclusion Assessed hospitals had the infrastructure and equipment to implement guideline-consistent care. While fluids, appropriate antimalarials and antibiotics, and malnutrition refeeding adherence was comparable to published estimates from low- and high-resource settings, there were inconsistencies in implementation of some other recommendations. Stockouts of essential therapeutics and laboratory reagents were a noted barrier, but facility staff perceived inadequate human resources as the primary constraint to consistent guideline implementation.
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Affiliation(s)
- Kirkby D. Tickell
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Dorothy I. Mangale
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Stephanie N. Tornberg-Belanger
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Celine Bourdon
- Program in Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | | | - Jenala Njirammadzi
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Wieger Voskuijl
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
- Global Child Health Group, Emma Children’s Hospital, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Mohammod J. Chisti
- Centre for Nutrition & Food Security (CNFS), icddr, b, Dhaka, Bangladesh
| | - Tahmeed Ahmed
- Centre for Nutrition & Food Security (CNFS), icddr, b, Dhaka, Bangladesh
| | | | - Abdoulaye H. Diallo
- Department of Public Health, Centre MURAZ Research Institute, Ministry of Health, Bobo-Dioulasso, Burkina Faso
- Department of Public Health, University of Ouagadougou, Ouagadougou, Burkina Faso
| | - Issaka Ouédrago
- Department of Paediatrics, Banfora Regional Referral Hospital, Banfora, Burkina Faso
| | - Al Fazal Khan
- Centre for Nutrition & Food Security (CNFS), icddr, b, Dhaka, Bangladesh
| | - Ali F. Saleem
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Fehmina Arif
- Department of Paediatrics, Civil Hospital Karachi, Karachi, Pakistan
| | - Zaubina Kazi
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Ezekiel Mupere
- Department of Paediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - John Mukisa
- Department of Paediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | | | - Judd L. Walson
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Pediatrics, University of Washington, Seattle, Washington, United States of America
| | - Donna M. Denno
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Pediatrics, University of Washington, Seattle, Washington, United States of America
- Department of Health Services, University of Washington, Seattle, Washington, United States of America
- * E-mail:
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Ayieko P, Irimu G, Ogero M, Mwaniki P, Malla L, Julius T, Chepkirui M, Mbevi G, Oliwa J, Agweyu A, Akech S, Were F, English M. Effect of enhancing audit and feedback on uptake of childhood pneumonia treatment policy in hospitals that are part of a clinical network: a cluster randomized trial. Implement Sci 2019; 14:20. [PMID: 30832678 PMCID: PMC6398235 DOI: 10.1186/s13012-019-0868-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 02/04/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The World Health Organization (WHO) revised its clinical guidelines for management of childhood pneumonia in 2013. Significant delays have occurred during previous introductions of new guidelines into routine clinical practice in low- and middle-income countries (LMIC). We therefore examined whether providing enhanced audit and feedback as opposed to routine standard feedback might accelerate adoption of the new pneumonia guidelines by clinical teams within hospitals in a low-income setting. METHODS In this parallel group cluster randomized controlled trial, 12 hospitals were assigned to either enhanced feedback (n = 6 hospitals) or standard feedback (n = 6 hospitals) using restricted randomization. The standard (network) intervention delivered in both trial arms included support to improve collection and quality of patient data, provision of mentorship and team management training for pediatricians, peer-to-peer networking (meetings and social media), and multimodal (print, electronic) bimonthly hospital specific feedback reports on multiple indicators of evidence guideline adherence. In addition to this network intervention, the enhanced feedback group received a monthly hospital-specific feedback sheet targeting pneumonia indicators presented in multiple formats (graphical and text) linked to explicit performance goals and action plans and specific email follow up from a network coordinator. At the start of the trial, all hospitals received a standardized training on the new guidelines and printed booklets containing pneumonia treatment protocols. The primary outcome was the proportion of children admitted with indrawing and/or fast-breathing pneumonia who were correctly classified using new guidelines and received correct antibiotic treatment (oral amoxicillin) in the first 24 h. The secondary outcome was the proportion of correctly classified and treated children for whom clinicians changed treatment from oral amoxicillin to injectable antibiotics. RESULTS The trial included 2299 childhood pneumonia admissions, 1087 within the hospitals randomized to enhanced feedback intervention, and 1212 to standard feedback. The proportion of children who were correctly classified and treated in the first 24 h during the entire 9-month period was 38.2% (393 out of 1030) and 38.4% (410 out of 1068) in the enhanced feedback and standard feedback groups, respectively (odds ratio 1.11; 95% confidence interval [CI] 0.37-3.34; P = 0.855). However, in exploratory analyses, there was evidence of an interaction between type of feedback and duration (in months) since commencement of intervention, suggesting a difference in adoption of pneumonia policy over time in the enhanced compared to standard feedback arm (OR = 1.25, 95% CI 1.14 to 1.36, P < 0.001). CONCLUSIONS Enhanced feedback comprising increased frequency, clear messaging aligned with goal setting, and outreach from a coordinator did not lead to a significant overall effect on correct pneumonia classification and treatment during the 9-month trial. There appeared to be a significant effect of time (representing cumulative effect of feedback cycles) on adoption of the new policy in the enhanced feedback compared to standard feedback group. Future studies should plan for longer follow-up periods to confirm these findings. TRIAL REGISTRATION US National Institutes of Health-ClinicalTrials.gov identifier (NCT number) NCT02817971 . Registered September 28, 2016-retrospectively registered.
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Affiliation(s)
- Philip Ayieko
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Grace Irimu
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Morris Ogero
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Paul Mwaniki
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Lucas Malla
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Thomas Julius
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Mercy Chepkirui
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - George Mbevi
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Jacquie Oliwa
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Ambrose Agweyu
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Samuel Akech
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
| | - Fred Were
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Mike English
- Health Services Unit, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Opoka RO, Ssemata AS, Oyang W, Nambuya H, John CC, Karamagi C, Tumwine JK. Adherence to clinical guidelines is associated with reduced inpatient mortality among children with severe anemia in Ugandan hospitals. PLoS One 2019; 14:e0210982. [PMID: 30682097 PMCID: PMC6347145 DOI: 10.1371/journal.pone.0210982] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 01/04/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND In resource limited settings, there is variability in the level of adherence to clinical guidelines in the inpatient management of children with common conditions like severe anemia. However, there is limited data on the effect of adherence to clinical guidelines on inpatient mortality in children managed for severe anemia. METHODS We analyzed data from an uncontrolled before and after in-service training intervention to improve quality of care in Lira and Jinja regional referral hospitals in Uganda. Inpatient records of children aged 0 to 5 years managed as cases of 'severe anemia (SA)' were reviewed to ascertain adherence to clinical guidelines and compare inpatient deaths in SA children managed versus those not managed according to clinical guidelines. Logistic regression analysis was conducted to evaluate the relationship between clinical care factors and inpatient deaths amongst patients managed for SA. RESULTS A total of 1,131 children were assigned a clinical diagnosis of 'severe anemia' in the two hospitals. There was improvement in the level of care after the in-service training intervention with more children being managed according to clinical guidelines compared to the period before, 218/510 (42.7%) vs 158/621 (25.4%) (p < 0.001). Overall, children managed according to clinical guidelines had reduced risk of inpatient mortality compared to those not managed according to clinical guidelines, [OR 0.28, (95%, CI 0.14, 0.55), p = 0.001]. Clinical care factors associated with decreased risk of inpatient death included, having pre-transfusion hemoglobin done to confirm diagnosis [OR 0.5; 95% CI 0.29, 0.87], a co-morbid diagnosis of severe malaria [OR 0.4; 95% CI 0.25, 0.76], and being reviewed after admission by a clinician [OR 0.3; 95% CI 0.18, 0.59], while a co-morbid diagnosis of severe acute malnutrition was associated with increased risk of inpatient death [OR 4.2; 95% CI 2.15, 8.22]. CONCLUSION Children with suspected SA who are managed according to clinical guidelines have lower in-hospital mortality than those not managed according to the guidelines. Efforts to reduce inpatient mortality in SA children in resource-limited settings should focus on training and supporting health workers to adhere to clinical guidelines.
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Affiliation(s)
- Robert O. Opoka
- Department of Paediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Andrew S. Ssemata
- Department of Psychiatry, College of Health Sciences, Makerere University, Kampala, Uganda
| | - William Oyang
- Children’s Ward, Lira Regional Referral Hospital, Lira, Uganda
| | - Harriet Nambuya
- Nalufenya Children’s Ward, Jinja Regional Referral Hospital, Jinja, Uganda
| | - Chandy C. John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Charles Karamagi
- Department of Paediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - James K. Tumwine
- Department of Paediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda
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Akech S, Ayieko P, Irimu G, Stepniewska K, English M. Magnitude and pattern of improvement in processes of care for hospitalised children with diarrhoea and dehydration in Kenyan hospitals participating in a clinical network. Trop Med Int Health 2019; 24:73-80. [PMID: 30365213 PMCID: PMC6378700 DOI: 10.1111/tmi.13176] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE WHO recommends optimisation of available interventions to reduce deaths of under-five children with diarrhoea and dehydration (DD). Clinical networks may help improve practice across many hospitals but experience with such networks is scarce. We describe magnitude and patterns of changes in processes of care for children with DD over the first 3 years of a clinical network. METHODS Observational study involving children aged 2-59 months with DD admitted to 13 hospitals participating in the clinical network. Processes of individual patient care including agreement of assessment, diagnosis and treatment according to WHO guidelines were combined using the composite Paediatric Admission Quality of Care (PAQC) score (range 0-6). RESULTS Data from 7657 children were analysed and improvements in PAQC scores were observed. Predicted mean PAQC score for all the hospitals at enrolment was 59.8% (95% CI: 54.7, 64.9) but showed a wide variation (variance 10.7%, 95% CI: 5.8, 19.6). Overall mean PAQC score increased by 13.8% (95% CI: 8.7-18.9, SD between hospitals: ±8.2) in the first 12 months, with an average 0.9% (95% CI: 0.3-1.5, SD ± 1.0) increase per month and plateaued thereafter, and changes were similar in two groups of hospitals joining the network at different times. CONCLUSION Adherence to guidelines for children admitted with DD can be improved through participation in a clinical network but improvement is limited, not uniform for all aspects of care and contexts and occurs early. Future research should address these issues.
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Affiliation(s)
- Samuel Akech
- Kenya Medical Research Institute/Wellcome Trust Research ProgrammeNairobiKenya
| | - Phillip Ayieko
- Kenya Medical Research Institute/Wellcome Trust Research ProgrammeNairobiKenya
| | - Grace Irimu
- Kenya Medical Research Institute/Wellcome Trust Research ProgrammeNairobiKenya
- Department of Paediatrics and Child HealthUniversity of NairobiNairobiKenya
| | - Kasia Stepniewska
- Centre for Tropical MedicineNuffield Department of Clinical MedicineUniversity of OxfordOxfordUK
- Worldwide Antimalarial Resistance NetworkOxfordUK
| | - Mike English
- Kenya Medical Research Institute/Wellcome Trust Research ProgrammeNairobiKenya
- Centre for Tropical MedicineNuffield Department of Clinical MedicineUniversity of OxfordOxfordUK
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Irimu G, Ogero M, Mbevi G, Agweyu A, Akech S, Julius T, Nyamai R, Githang’a D, Ayieko P, English M. Approaching quality improvement at scale: a learning health system approach in Kenya. Arch Dis Child 2018; 103. [PMID: 29514814 PMCID: PMC6278651 DOI: 10.1136/archdischild-2017-314348] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Affiliation(s)
- Grace Irimu
- Wellcome Trust Research Programme, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya,Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Morris Ogero
- Wellcome Trust Research Programme, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - George Mbevi
- Wellcome Trust Research Programme, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Ambrose Agweyu
- Wellcome Trust Research Programme, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Samuel Akech
- Wellcome Trust Research Programme, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Thomas Julius
- Wellcome Trust Research Programme, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Rachel Nyamai
- Maternal, Newborn, Child and Adolescent Health Unit, Ministry of Health, Nairobi, Kenya
| | | | - Philip Ayieko
- Wellcome Trust Research Programme, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Mike English
- Wellcome Trust Research Programme, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya,Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Gile PP, Buljac-Samardzic M, Klundert JVD. The effect of human resource management on performance in hospitals in Sub-Saharan Africa: a systematic literature review. Hum Resour Health 2018; 16:34. [PMID: 30068356 PMCID: PMC6090989 DOI: 10.1186/s12960-018-0298-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 07/09/2018] [Indexed: 05/26/2023]
Abstract
Hospitals in Sub-Saharan Africa (SSA) face major workforce challenges while having to deal with extraordinary high burdens of disease. The effectiveness of human resource management (HRM) is therefore of particular interest for these SSA hospitals. While, in general, the relationship between HRM and hospital performance is extensively investigated, most of the underlying empirical evidence is from western countries and may have limited validity in SSA. Evidence on this relationship for SSA hospitals is scarce and scattered. We present a systematic review of empirical studies investigating the relationship between HRM and performance in SSA hospitals.Following the PRISMA protocol, searching in seven databases (i.e., Embase, MEDLINE, Web of Science, Cochrane, PubMed, CINAHL, Google Scholar) yielded 2252 hits and a total of 111 included studies that represent 19 out of 48 SSA countries.From a HRM perspective, most studies researched HRM bundles that combined practices from motivation-enhancing, skills-enhancing, and empowerment-enhancing domains. Motivation-enhancing practices were most frequently researched, followed by skills-enhancing practices and empowerment-enhancing practices. Few studies focused on single HRM practices (instead of bundles). Training and education were the most researched single practices, followed by task shifting.From a performance perspective, our review reveals that employee outcomes and organizational outcomes are frequently researched, whereas team outcomes and patient outcomes are significantly less researched. Most studies report HRM interventions to have positively impacted performance in one way or another. As researchers have studied a wide variety of (bundled) interventions and outcomes, our analysis does not allow to present a structured set of effective one-to-one relationships between specific HRM interventions and performance measures. Instead, we find that specific outcome improvements can be accomplished by different HRM interventions and conversely that similar HRM interventions are reported to affect different outcome measures.In view of the high burden of disease, our review identified remarkable little evidence on the relationship between HRM and patient outcomes. Moreover, the presented evidence often fails to provide contextual characteristics which are likely to induce variety in the performance effects of HRM interventions. Coordinated research efforts to advance the evidence base are called for.
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Affiliation(s)
- Philipos Petros Gile
- Higher Education Institutions’ Partnership, PO BOX 14051, Addis Ababa, Ethiopia
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, PO Box 1738, 3000 DR Rotterdam, The Netherlands
| | - Martina Buljac-Samardzic
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, PO Box 1738, 3000 DR Rotterdam, The Netherlands
| | - Joris Van De Klundert
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, PO Box 1738, 3000 DR Rotterdam, The Netherlands
- Prince Mohammad Bin Salman College (MBSC) of Business & Entrepreneurship, 7082-BayLaSun-Juman St. Unit No. 1, King Abdullah Economic City, 23964-2522 Kingdom of Saudi Arabia
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Wanzira H, Muyinda R, Lochoro P, Putoto G, Segafredo G, Wamani H, Lazzerini M. Quality of care for children with acute malnutrition at health center level in Uganda: a cross sectional study in West Nile region during the refugee crisis. BMC Health Serv Res 2018; 18:561. [PMID: 30016954 PMCID: PMC6050688 DOI: 10.1186/s12913-018-3366-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 07/08/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Arua district, in Uganda, hosts some of the largest refugee camps in the country. The estimated prevalence of moderate and severe acute malnutrition in children is higher than the national estimates (10.4 and 5.6% respectively, compared to 3.6 and 1.3%). This study aimed at assessing the quality of care provided to children with acute malnutrition at out-patient level in such a setting. METHODS Six facilities with the highest number of children with malnutrition were selected. The main tool used was the National Nutrition Service Delivery Assessment Tool, assessing 10 key areas of service delivery and assigned a score as either poor, fair, good or excellent. Health outcomes, quality of case management and data quality were assessed from the health management information system and from the official nutrition registers. RESULTS All facilities except two scored either poor or fair under all the 10 assessment areas. Overall, 33/60 (55%) areas scored as poor, 25/60 (41%) as fair, 2/60 (3.3%) as good, and none as excellent. Main gaps identified included: lack of trained staff; disorganised patient flow; poor case management; stock out of essential supplies including ready-to-use therapeutic foods; weak community linkage. A sample coverage of 45.4% (1020/2248) of total children admitted in the district during the 2016 financial year were included. The overall mean cure rate was 52.9% while the default rate was 38.3%. There was great heterogeneity across health facilities in health outcomes, quality of case management, and data quality. CONCLUSION This study suggests that quality of care provided to children with malnutrition at health center level is substandard with unacceptable low cure rates. It is essential to identify effective approaches to enhance adherence to national guidelines, provision of essential nutritional commodities, regular monitoring of services and better linkage with the community through village health teams.
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Affiliation(s)
- Humphrey Wanzira
- WHO Collaborating Centre for Maternal and Child Health, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
| | | | | | | | | | - Henry Wamani
- Makerere University School of Public Health, Kampala, Uganda
| | - Marzia Lazzerini
- WHO Collaborating Centre for Maternal and Child Health, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
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Affiliation(s)
- Trevor Duke
- Centre for International Child Health, University of Melbourne, Department of Paediatrics and Intensive Care Unit, Royal Children's Hospital, Parkville, Victoria, Australia.,School of Medicine and Health Sciences, University of Papua New Guinea, Papua New Guinea
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