@article {1572766, title = {Regional determinants of quality of care for sick children: A multilevel analysis in four countries}, journal = {Journal of Global Health}, year = {2024}, abstract = {

Background

The limited impact of increased access to care on improvements in health outcomes during the Millennium Development Goal era has been attributed, in part, to inadequate quality of care. We identified regional factors associated with health service quality for sick child care in low-income countries and examined whether provider factors interact with regional factors to affect the quality of care.

Methods

We conducted cross-sectional random intercept four-level linear regression using the most recent Service Provision Assessment and Demographic Health Survey data from four countries (467 from the Democratic Republic of Congo 2018, 2425 from Afghanistan 2018, 2072 from Nepal 2015, and 813 from Senegal 2017). The outcome variable was the service quality score for sick child care, which was measured as the percentage of clinically recommended tasks completed in the integrated management of childhood illness (ranging from 0 to 100). Regional factors were selected based on the High-Quality Health System Framework.

Results

The service quality score was found to be positively associated with the proportion of large facilities (β = 8.61;\ P = 0.004) and the proportion of providers ranked in the top fifth for service quality score (β = 30.15;\ P \< 0.001) in the region. We identified significant cross-level interactions between provider qualifications (β = -16.6;\ P \< 0.001) or job descriptions (β = 12.01;\ P = 0.002) and the proportion of providers in the top fifth for service quality scores within the region. As the proportion of top-performing providers in a region increased, the increase in the service quality score was more pronounced among providers who were nonmedical doctors or did not have job descriptions than among their counterparts.

Conclusions

Our findings indicate that the quality of care for sick children in a region improves with a greater proportion of high-performing providers or larger facilities. Providers who are not medical doctors, or those who have specific job descriptions, tend to benefit more from the presence of these top-performing providers.

}, url = {https://jogh.org/2024/jogh-14-04053}, author = {Hwa-Young Lee and Jan E. Cooper and Margaret E. Kruk} } @article {1439177, title = { Making health and social systems work for all children in low-income and middle-income countries: structural innovations to deliver high quality services. The Lancet 2022}, year = {2022}, url = {https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)02532-0/fulltext?dgcid=raven_jbs_etoc_email}, author = {Margaret E. Kruk and Todd Lewis and Catherine Arsenault and Bhutta, Zulfiqar A and Irimu G and Joeng J and Lassi Z and Sawyer S and Vaivada T and Waiswa P and Yousafzai AK} } @article {1396285, title = {Association between a complex community intervention and quality of health extension workers{\textquoteright} performance to correctly classify common childhood illnesses in four regions of Ethiopia}, journal = {PLoS One}, volume = {16}, year = {2021}, month = {2021}, pages = {e0247474}, abstract = {BACKGROUND: Due to low care utilization, a complex intervention was done for two years to optimize the Ethiopian Health Extension Program. Improved quality of the integrated community case management services was an intermediate outcome of this intervention through community education and mobilization, capacity building of health workers, and strengthening of district ownership and accountability of sick child services. We evaluated the association between the intervention and the health extension workers{\textquoteright} ability to correctly classify common childhood illnesses in four regions of Ethiopia. METHODS: Baseline and endline assessments were done in 2016 and 2018 in intervention and comparison areas in four regions of Ethiopia. Ill children aged 2 to 59 months were mobilized to visit health posts for an assessment that was followed by re-examination. We analyzed sensitivity, specificity, and difference-in-difference of correct classification with multilevel mixed logistic regression in intervention and comparison areas at baseline and endline. RESULTS: Health extensions workers{\textquoteright} consultations with ill children were observed in intervention (n = 710) and comparison areas (n = 615). At baseline, re-examination of the children showed that in intervention areas, health extension workers{\textquoteright} sensitivity for fever or malaria was 54\%, 68\% for respiratory infections, 90\% for diarrheal diseases, and 34\% for malnutrition. At endline, it was 40\% for fever or malaria, 49\% for respiratory infections, 85\% for diarrheal diseases, and 48\% for malnutrition. Specificity was higher (89-100\%) for all childhood illnesses. Difference-in-differences was 6\% for correct classification of fever or malaria [aOR = 1.45 95\% CI: 0.81-2.60], 4\% for respiratory tract infection [aOR = 1.49 95\% CI: 0.81-2.74], and 5\% for diarrheal diseases [aOR = 1.74 95\% CI: 0.77-3.92]. CONCLUSION: This study revealed that the Optimization of Health Extension Program intervention, which included training, supportive supervision, and performance reviews of health extension workers, was not associated with an improved classification of childhood illnesses by these Ethiopian primary health care workers. TRIAL REGISTRATION: ISRCTN12040912, http://www.isrctn.com/ISRCTN12040912.}, issn = {1932-6203}, doi = {10.1371/journal.pone.0247474}, author = {Getachew, Theodros and Abebe, Solomon Mekonnen and Yitayal, Mezgebu and Persson, Lars {\r A}ke and Berhanu, Della} } @article {1396313, title = {The COVID-19 pandemic: A call to action for health systems in Latin America to strengthen quality of care}, journal = {Int J Qual Health Care}, volume = {33}, year = {2021}, month = {2021 Mar 05}, abstract = {The Covid-19 and other recent pandemics has highlighted existing weakness in health systems across the Latin-America and the Caribbean (LAC) region to effectively prepare for and respond to Public Health Emergencies. It has been stated that quality of care will be among the most influential factors on Covid 19 mortality rates and low systems performance is the common case in these countries. More comprehensive and system level strategies are required to address the challenges. These must focus on redesigning and strengthening health systems to make them more resilient to the changing needs of populations and based on quality improvement methods that have shown rigorously evaluated positive effects in previous local and regional experiences. A call to action is being made by the Latin American Consortium for Quality, Patient Safety and Innovation (CLICSS) and they provide specific recommendations for decision makers.}, issn = {1464-3677}, doi = {10.1093/intqhc/mzaa062}, author = {Ezequiel, Garcia Elorrio and Jafet, Arrieta and Hugo, Arce and Pedro, Delgado and Ana Maria, Malik and Carola, Orrego Villagran and Sofia, Rincon and Odet, Sarabia and Teresa, Tono and Jorge, Hermida and Enrique, Ruelas Barajas} } @article {1417611, title = {Disruption in essential health services in Mexico during COVID-19: an interrupted time series analysis of health information system data}, journal = {BMJ Glob Health}, volume = {6}, year = {2021}, month = {2021 09}, abstract = {INTRODUCTION: The COVID-19 pandemic has disrupted health systems around the world. The objectives of this study are to estimate the overall effect of the pandemic on essential health service use and outcomes in Mexico, describe observed and predicted trends in services over 24 months, and to estimate the number of visits lost through December 2020. METHODS: We used health information system data for January 2019 to December 2020 from the Mexican Institute of Social Security (IMSS), which provides health services for more than half of Mexico{\textquoteright}s population-65 million people. Our analysis includes nine indicators of service use and three outcome indicators for reproductive, maternal and child health and non-communicable disease services. We used an interrupted time series design and linear generalised estimating equation models to estimate the change in service use and outcomes from April to December 2020. Estimates were expressed using average marginal effects on the risk ratio scale. RESULTS: The study found that across nine health services, an estimated 8.74 million patient visits were lost in Mexico. This included a decline of over two thirds for breast and cervical cancer screenings (79\% and 68\%, respectively), over half for sick child visits and female contraceptive services, approximately one-third for childhood vaccinations, diabetes, hypertension and antenatal care consultations, and a decline of 10\% for deliveries performed at IMSS. In terms of patient outcomes, the proportion of patients with diabetes and hypertension with controlled conditions declined by 22\% and 17\%, respectively. Caesarean section rate did not change. CONCLUSION: Significant disruptions in health services show that the pandemic has strained the resilience of the Mexican health system and calls for urgent efforts to resume essential services and plan for catching up on missed preventive care even as the COVID-19 crisis continues in Mexico.}, keywords = {Cesarean Section, Child, COVID-19, Female, Health Information Systems, Health Services, Humans, Interrupted Time Series Analysis, mexico, Pandemics, Pregnancy, SARS-CoV-2}, issn = {2059-7908}, doi = {10.1136/bmjgh-2021-006204}, author = {Doubova, Svetlana V and Leslie, Hannah H and Margaret E Kruk and P{\'e}rez-Cuevas, Ricardo and Catherine Arsenault} } @article {1396324, title = {Health care provider time in public primary care facilities in Lima, Peru: a cross-sectional time motion study}, journal = {BMC Health Serv Res}, volume = {21}, year = {2021}, month = {2021 Feb 06}, pages = {123}, abstract = {BACKGROUND: In Peru, a majority of individuals bypass primary care facilities even for routine services. Efforts to strengthen primary care must be informed by understanding of current practice. We conducted a time motion assessment in primary care facilities in Lima with the goals of assessing the feasibility of this method in an urban health care setting in Latin America and of providing policy makers with empirical evidence on the use of health care provider time in primary care. METHODS: This cross-sectional continuous observation time motion study took place from July - September 2019. We used two-stage sampling to draw a sample of shifts for doctors, nurses, and midwives in primary health facilities and applied the Work Observation Method by Activity Timing tool to capture type and duration of provider activities over a 6-h shift. We summarized time spent on patient care, paper and electronic record-keeping, and non-work (personal and inactive) activities across provider cadres. Observations are weighted by inverse probability of selection. RESULTS: Two hundred seventy-five providers were sampled from 60 facilities; 20\% could not be observed due to provider absence (2\% schedule error, 8\% schedule change, 10\% failure to appear). One hundred seventy-four of the 220 identified providers consented (79.1\%) and were observed for a total of 898 h of provider time comprising 30,312 unique tasks. Outpatient shifts included substantial time on patient interaction (110, 82, and 130 min for doctors, nurses, and midwives respectively) and on paper records (132, 97, and 141 min) on average. Across all shifts, 1 in 6 h was spent inactive or on personal activities. Two thirds of midwives used computers compared to half of nurses and one third of doctors. CONCLUSIONS: The time motion study is a feasible method to capture primary care operations in Latin American countries and inform health system strengthening. In the case of Lima, absenteeism undermines health worker availability in primary care facilities, and inactive time further erodes health workforce availability. Productive time is divided between patient-facing activities and a substantial burden of paper-based record keeping for clinical and administrative purposes. Electronic health records remain incompletely integrated within routine care, particularly beyond midwifery.}, issn = {1472-6963}, doi = {10.1186/s12913-021-06117-9}, author = {Leslie, Hannah H and Laos, Denisse and C{\'a}rcamo, Cesar and P{\'e}rez-Cuevas, Ricardo and Garc{\'\i}a, Patricia J} } @article {Nimako, title = {Health System Redesign to Shift to Hospital Delivery for Maternal and Newborn Survival: Feasibility Assessment in Kakamega County, Kenya}, journal = {Global Health: Science and Practice}, year = {2021}, publisher = {Global Health: Science and Practice}, abstract = {Key FindingsMaternal and newborn health service delivery redesign (MNH redesign) is a policy to shift all deliveries to or close to hospitals.Current system assets that support MNH redesign in Kakamega County are the adequate geographic spread of hospitals, close proximity of women to these hospitals, and high provider and user support for the concept.Before MNH redesign is implemented in Kakamega County, prevailing health system deficits, like health provider shortages and transportation challenges for mothers, would need to be addressed.Key ImplicationsThe county, in partnership with health system researchers, should rigorously evaluate the process of implementing MNH redesign and its impact on health, to learn and test the model and to serve as a base for generalizing uptake across the country.Countries that seek to implement MNH redesign would need to similarly assess feasibility to determine the assets and gaps for implementation.Maternal and newborn health (MNH) service delivery redesign aims to improve maternal and newborn survival by shifting deliveries from poorly equipped primary care facilities to adequately prepared designated delivery hospitals. We assess the feasibility of such a model in Kakamega County, Kenya, by determining the capacity of hospitals to provide services under the redesigned model and the acceptability of the concept to providers and users. We find many existing system assets to implement redesign, including political will to improve MNH outcomes, a strong base of support among providers and users, and a good geographic spread of facilities to support implementation. There are nonetheless health workforce gaps, infrastructure deficits, and transportation challenges that would need to be addressed ahead of policy rollout. Implementing MNH redesign would require careful planning to limit unintended consequences and rigorous evaluation to assess impact and inform scale-up.}, doi = {10.9745/GHSP-D-20-00684}, url = {https://www.ghspjournal.org/content/early/2021/11/24/GHSP-D-20-00684}, author = {Nimako, Kojo and Anna Gage and Benski, Caroline and Sanam Roder-DeWan and Ali, Khatra and Kandie, Charles and Mohamed, Aisha and Odeny, Hellen and Oloo, Micky and Otieno, John Tolo Boston and Wanzala, Maximilla and Okumu, Rachel and Margaret E. Kruk} } @article {10.1371/journal.pmed.1003843, title = {Hospital delivery and neonatal mortality in 37 countries in sub-Saharan Africa and South Asia: An ecological study}, journal = {PLOS Medicine}, volume = {18}, year = {2021}, month = {12}, pages = {1-14}, publisher = {Public Library of Science}, abstract = {Background Widespread increases in facility delivery have not substantially reduced neonatal mortality in sub-Saharan Africa and South Asia over the past 2 decades. This may be due to poor quality care available in widely used primary care clinics. In this study, we examine the association between hospital delivery and neonatal mortality. Methods and findings We used an ecological study design to assess cross-sectional associations between the share of hospital delivery and neonatal mortality across country regions. Data were from the Demographic and Health Surveys from 2009 to 2018, covering 682,239 births across all regions. We assess the association between the share of facility births in a region that occurred in hospitals (versus lower-level clinics) and early (0 to 7 days) neonatal mortality per 1,000 births, controlling for potential confounders including the share of facility births, small at birth, maternal age, maternal education, urbanicity, antenatal care visits, income, region, and survey year. We examined changes in this association in different contexts of country income, global region, and urbanicity using interaction models. Across the 1,143 regions from 37 countries in sub-Saharan Africa and South Asia, 42\%, 29\%, and 28\% of births took place in a hospital, clinic, and at home, respectively. A 10-percentage point higher share of facility deliveries occurring in hospitals was associated with 1.2 per 1,000 fewer deaths (p-value \< 0.01; 95\% CI: 0.82 to 1.60), relative to mean mortality of 22. Associations were strongest in South Asian countries, middle-income countries, and urban regions. The study{\textquoteright}s limitations include the inability to control for all confounding factors given the ecological and cross-sectional design and potential misclassification of facility levels in our data. Conclusions Regions with more hospital deliveries than clinic deliveries have reduced neonatal mortality. Increasing delivery in hospitals while improving quality across the health system may help to reduce high neonatal mortality.}, doi = {10.1371/journal.pmed.1003843}, url = {https://doi.org/10.1371/journal.pmed.1003843}, author = {Gage, Anna D. and Fink, G{\"u}nther and Ataguba, John E. and Margaret E. Kruk} } @article {1416559, title = {Seizing the moment to rethink health systems}, journal = {Lancet Glob Health}, year = {2021}, month = {2021 Sep 07}, abstract = {The COVID-19 pandemic has made vivid the need for resilient, high-quality health systems and presents an opportunity to reconsider how to build such systems. Although even well resourced, well performing health systems have struggled at various points to cope with surges of COVID-19, experience suggests that establishing health system foundations based on clear aims, adequate resources, and effective constraints and incentives is crucial for consistent provision of high-quality care, and that these cannot be replaced by piecemeal quality improvement interventions. We identify four mutually reinforcing structural investments that could transform health system performance in resource-constrained countries: revamping health provider education, redesigning platforms for care delivery, instituting strategic purchasing and management strategies, and developing patient-level data systems. Countries should seize the political and moral energy provided by the COVID-19 pandemic to build health systems fit for the future.}, issn = {2214-109X}, doi = {10.1016/S2214-109X(21)00356-9}, author = {Nimako, Kojo and Margaret E Kruk} } @article {1396266, title = {Are health care assistants part of the long-term solution to the nursing workforce deficit in Kenya?}, journal = {Hum Resour Health}, volume = {18}, year = {2020}, month = {2020 10 20}, pages = {79}, abstract = {This commentary article addresses a critical issue facing Kenya and other Low- and Middle-Income Countries (LMIC): how to remedy deficits in hospitals{\textquoteright} nursing workforce. Would employing health care assistants (HCAs) provide a partial solution? This article first gives a brief introduction to the Kenyan context and then explores the development of workforce roles to support nurses in Europe to highlight the diversity of these roles. Our introduction pinpoints that pressures to maintain or restrict costs have led to a wide variety of formal and informal task shifting from nurses to some form of HCA in the EU with differences noted in issues of appropriate skill mix, training, accountability, and regulation of HCA. Next, we draw from a suite of recent studies in hospitals in Kenya which illustrate nursing practices in a highly pressurized context. The studies took place in neo-natal wards in Kenyan hospitals between 2015 and 2018 and in a system with no legal or regulatory basis for task shifting to HCAs. We proffer data on why and how nurses informally delegate tasks to others in the public sector and the decision-making processes of nurses and frame this evidence in the specific contextual conditions. In the conclusion, the paper aims to deepen the debates on developing human resources for health. We argue that despite the urgent pressures to address glaring workforce deficits in Kenya and other LMIC, caution needs to be exercised in implementing changes to nursing practices through the introduction of HCAs. The evidence from EU suggests that the rapid growth in the employment of HCA has created crucial issues which need addressing. These include clearly defining the scope of practice and developing the appropriate skill mix between nurses and HCAs to match the specific health system context. Moreover, we suggest efforts to develop and implement such roles should be carefully designed and rigorously evaluated to inform continuing policy development.}, issn = {1478-4491}, doi = {10.1186/s12960-020-00523-6}, author = {Fitzgerald, Louise and Gathara, David and McKnight, Jacob and Nzinga, Jacinta and Mike English} } @article {1396281, title = {Assessing the quality of care in sick child services at health facilities in Ethiopia}, journal = {BMC Health Serv Res}, volume = {20}, year = {2020}, month = {2020 Jun 23}, pages = {574}, abstract = {BACKGROUND: Quality of care depends on system, facility, provider, and client-level factors. We aimed at examining structural and process quality of services for sick children and its association with client satisfaction at health facilities in Ethiopia. METHODS: Data from the Ethiopia Service Provision Assessment Plus (SPA+) survey 2014 were used. Measures of quality were assessed based on the Donabedian framework: structure, process, and outcome. A total of 1908 mothers or caretakers were interviewed and their child consultations were observed. Principal component analysis was used to construct quality of care indices including a structural composite score, a process composite score, and a client satisfaction score. Multilevel mixed linear regression was used to analyze the association between structural and process factors with client satisfaction. RESULT: Among children diagnosed with suspected pneumonia, respiratory rate was counted in 56\% and temperature was checked in 77\% of the cases. A majority of children (92\%) diagnosed with fever had their temperature taken. Only 3\% of children with fever were either referred or admitted, and 60\% received antibiotics. Among children diagnosed with malaria, 51\% were assessed for all three Integrated Management of Childhood Illnesses (IMCI) main symptoms, and 4\% were assessed for all three general danger signs. Providers assessed dehydration in 54\% of children with diarrhea with dehydration, 17\% of these children were admitted or referred to another facility, and Oral Rehydration Solution was prescribed for 67\% while none received intravenous fluids. The number of basic amenities in the facility was negatively associated with the clients{\textquoteright} satisfaction. Private facilities, when the providers had got training for care of sick children in the past 2\ years, had higher client satisfaction. There was no statistical association between structure, process composite indicators and client satisfaction. CONCLUSION: The assessment of sick children was of low quality, with many missing procedures when comparing with IMCI guidelines. In spite of this, most clients were satisfied with the services they received. Structural and process composite indicators were not associated with client{\textquoteright}s satisfaction. These findings highlight the need to assess other dimensions of quality of care besides structure and process that may influence client satisfaction.}, keywords = {Child, Child Health Services, Dehydration, Ethiopia, Female, Fever, Health Care Surveys, Health Facilities, Humans, Malaria, Patient Satisfaction, Pneumonia, Practice Guidelines as Topic, Quality of Health Care}, issn = {1472-6963}, doi = {10.1186/s12913-020-05444-7}, author = {Getachew, Theodros and Abebe, Solomon Mekonnen and Yitayal, Mezgebu and Persson, Lars {\r A}ke and Berhanu, Della} } @article {1396283, title = {Availability of equipment and medications for non-communicable diseases and injuries at public first-referral level hospitals: a cross-sectional analysis of service provision assessments in eight low-income countries}, journal = {BMJ Open}, volume = {10}, year = {2020}, month = {2020 10 10}, pages = {e038842}, abstract = {CONTEXT AND OBJECTIVES: Non-communicable diseases and injuries (NCDIs) comprise a large share of mortality and morbidity in low-income countries (LICs), many of which occur earlier in life and with greater severity than in higher income settings. Our objective was to assess availability of essential equipment and medications required for a broad range of acute and chronic NCDI conditions. DESIGN: Secondary analysis of existing cross-sectional survey data. SETTING: We used data from Service Provision Assessment surveys in Bangladesh, the Democratic Republic of the Congo, Ethiopia, Haiti, Malawi, Nepal, Senegal and Tanzania, focusing on public first-referral level hospitals in each country. OUTCOME MEASURES: We defined sets of equipment and medications required for diagnosis and management of four acute and nine chronic NCDI conditions and determined availability of these items at the health facilities. RESULTS: Overall, 797 hospitals were included. Medication and equipment availability was highest for acute epilepsy (country estimates ranging from 40\% to 95\%) and stage 1-2 hypertension (28\%-83\%). Availability was low for type 1 diabetes (1\%-70\%), type 2 diabetes (3\%-57\%), asthma (0\%-7\%) and acute presentations of diabetes (0\%-26\%) and asthma (0\%-4\%). Few hospitals had equipment or medications for heart failure (0\%-32\%), rheumatic heart disease (0\%-23\%), hypertensive emergencies (0\%-64\%) or acute minor surgical conditions (0\%-5\%). Data for chronic pain were limited to only two countries. Availability of essential medications and equipment was lower than previous facility-reported service availability. CONCLUSIONS: Our findings demonstrate low availability of essential equipment and medications for diverse NCDIs at first-referral level hospitals in eight LICs. There is a need for decentralisation and integration of NCDI services in existing care platforms and improved assessment and monitoring to fully achieve universal health coverage.}, issn = {2044-6055}, doi = {10.1136/bmjopen-2020-038842}, author = {Gupta, Neil and Coates, Matthew M and Bekele, Abebe and Dupuy, Roodney and F{\'e}nelon, Darius Leopold and Gage, Anna D and Getachew, Theodros and Karmacharya, Biraj Man and Kwan, Gene F and Lulebo, Aim{\'e}e M and Masiye, Jones K and Mayige, Mary Theodory and Ndour Mbaye, Ma{\"\i}mouna and Mridha, Malay Kanti and Park, Paul H and Dagnaw, Wubaye Walelgne and Wroe, Emily B and Bukhman, Gene} } @article {1396262, title = {Developing metrics for nursing quality of care for low- and middle-income countries: a scoping review linked to stakeholder engagement}, journal = {Hum Resour Health}, volume = {18}, year = {2020}, month = {2020 05 14}, pages = {34}, abstract = {BACKGROUND: The use of appropriate and relevant nurse-sensitive indicators provides an opportunity to demonstrate the unique contributions of nurses to patient outcomes. The aim of this work was to develop relevant metrics to assess the quality of nursing care in low- and middle-income countries (LMICs) where they are scarce. MAIN BODY: We conducted a scoping review using EMBASE, CINAHL and MEDLINE databases of studies published in English focused on quality nursing care and with identified measurement methods. Indicators identified were reviewed by a diverse panel of nursing stakeholders in Kenya to develop a contextually appropriate set of nurse-sensitive indicators for Kenyan hospitals specific to the five major inpatient disciplines. We extracted data on study characteristics, nursing indicators reported, location and the tools used. A total of 23 articles quantifying the quality of nursing care services met the inclusion criteria. All studies identified were from high-income countries. Pooled together, 159 indicators were reported in the reviewed studies with 25 identified as the most commonly reported. Through the stakeholder consultative process, 52 nurse-sensitive indicators were recommended for Kenyan hospitals. CONCLUSIONS: Although nurse-sensitive indicators are increasingly used in high-income countries to improve quality of care, there is a wide heterogeneity in the way indicators are defined and interpreted. Whilst some indicators were regarded as useful by a Kenyan expert panel, contextual differences prompted them to recommend additional new indicators to improve the evaluations of nursing care provision in Kenyan hospitals and potentially similar LMIC settings. Taken forward through implementation, refinement and adaptation, the proposed indicators could be more standardised and may provide a common base to establish national or regional professional learning networks with the common goal of achieving high-quality care through quality improvement and learning.}, issn = {1478-4491}, doi = {10.1186/s12960-020-00470-2}, author = {Gathara, David and Zosi, Mathias and Serem, George and Nzinga, Jacinta and Murphy, Georgina A V and Jackson, Debra and Brownie, Sharon and Mike English} } @article {1396284, title = {Does a complex intervention targeting communities, health facilities and district health managers increase the utilisation of community-based child health services? A before and after study in intervention and comparison areas of Ethiopia}, journal = {BMJ Open}, volume = {10}, year = {2020}, month = {2020 09 15}, pages = {e040868}, abstract = {INTRODUCTION: Ethiopia successfully reduced mortality in children below 5 years of age during the past few decades, but the utilisation of child health services was still low. Optimising the Health Extension Programme was a 2-year intervention in 26 districts, focusing on community engagement, capacity strengthening of primary care workers and reinforcement of district accountability of child health services. We report the intervention{\textquoteright}s effectiveness on care utilisation for common childhood illnesses. METHODS: We included a representative sample of 5773 households with 2874 under-five children at baseline (December 2016 to February 2017) and 10 788 households and 5639 under-five children at endline surveys (December 2018 to February 2019) in intervention and comparison areas. Health facilities were also included. We assessed the effect of the intervention using difference-in-differences analyses. RESULTS: There were 31 intervention activities; many were one-off and implemented late. In eight districts, activities were interrupted for 4 months. Care-seeking for any illness in the 2 weeks before the survey for children aged 2-59 months at baseline was 58\% (95\% CI 47 to 68) in intervention and 49\% (95\% CI 39 to 60) in comparison areas. At end-line it was 39\% (95\% CI 32 to 45) in intervention and 34\% (95\% CI 27 to 41) in comparison areas (difference-in-differences -4 percentage points, adjusted OR 0.49, 95\% CI 0.12 to 1.95). The intervention neither had an effect on care-seeking among sick neonates, nor on household participation in community engagement forums, supportive supervision of primary care workers, nor on indicators of district accountability for child health services. CONCLUSION: We found no evidence to suggest that the intervention increased the utilisation of care for sick children. The lack of effect could partly be attributed to the short implementation period of a complex intervention and implementation interruption. Future funding schemes should take into consideration that complex interventions that include behaviour change may need an extended implementation period. TRIAL REGISTRATION NUMBER: ISRCTN12040912.}, issn = {2044-6055}, doi = {10.1136/bmjopen-2020-040868}, author = {Berhanu, Della and Okwaraji, Yemisrach Behailu and Defar, Atkure and Bekele, Abebe and Ephrem Tekle Lemango and Medhanyie, Araya Abrha and Wordofa, Muluemebet Abera and Yitayal, Mezgebu and W/Gebriel, Fitsum and Desta, Alem and Gebregizabher, Fisseha Ashebir and Daka, Dawit Wolde and Hunduma, Alemayehu and Beyene, Habtamu and Getahun, Tigist and Getachew, Theodros and Woldemariam, Amare Tariku and Wolassa, Desta and Persson, Lars {\r A}ke and Schellenberg, Joanna} } @article {1396515, title = {Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap}, journal = {BMJ Glob Health}, volume = {5}, year = {2020}, month = {2020 10}, abstract = {Large disparities in maternal and neonatal mortality exist between low- and high-income countries. Mothers and babies continue to die at high rates in many countries despite substantial increases in facility birth. One reason for this may be the current design of health systems in most low-income countries where, unlike in high-income countries, a substantial proportion of births occur in primary care facilities that cannot offer definitive care for complications. We argue that the current inequity in care for childbirth is a global double standard that limits progress on maternal and newborn survival. We propose that health systems need to be redesigned to shift all deliveries to hospitals or other advanced care facilities to bring care in line with global best practice. Health system redesign will require investing in high-quality hospitals with excellent midwifery and obstetric care, boosting quality of primary care clinics for antenatal, postnatal, and newborn care, decreasing access and financial barriers, and mobilizing populations to demand high-quality care. Redesign is a structural reform that is contingent on political leadership that envisions a health system designed to deliver high-quality, respectful care to all women giving birth. Getting redesign right will require focused investments, local design and adaptation, and robust evaluation.}, issn = {2059-7908}, doi = {10.1136/bmjgh-2020-002539}, author = {Sanam Roder-DeWan and Nimako, Kojo and Nana A Y Twum-Danso and Amatya, Archana and Langer, Ana and Margaret Kruk} } @article {1396287, title = {Health systems and global progress towards malaria elimination, 2000-2016}, journal = {Malar J}, volume = {19}, year = {2020}, month = {2020 Apr 08}, pages = {141}, abstract = {BACKGROUND: As more countries progress towards malaria elimination, a better understanding of the most critical health system features for enabling and supporting malaria control and elimination is needed. METHODS: All available health systems data relevant for malaria control were collated from 23 online data repositories. Principal component analysis was used to create domain specific health system performance measures. Multiple regression model selection approaches were used to identify key health systems predictors of progress in malaria control in the 2000-2016 period among 105 countries. Additional analysis was performed within malaria burden groups. RESULTS: There was large heterogeneity in progress in malaria control in the 2000-2016 period. In univariate analysis, several health systems factors displayed a strong positive correlation with reductions in malaria burden between 2000 and 2016. In multivariable models, delivery of routine services and hospital capacity were strongly predictive of reductions in malaria cases, especially in high burden countries. In low-burden countries approaching elimination, primary health center density appeared negatively associated with progress while hospital capacity was positively correlated with eliminating malaria. CONCLUSIONS: The findings presented in this manuscript suggest that strengthening health systems can be an effective strategy for reducing malaria cases, especially in countries with high malaria burden. Potential returns appear particularly high in the area of service delivery.}, keywords = {Disease Eradication, Global Health, Humans, Malaria, Regression Analysis}, issn = {1475-2875}, doi = {10.1186/s12936-020-03208-6}, author = {Sahu, Maitreyi and Tediosi, Fabrizio and Noor, Abdisalan M and Aponte, John J and Fink, G{\"u}nther} } @article {1396270, title = {Hospital-provision of essential primary care in 56 countries: determinants and quality}, journal = {Bull World Health Organ}, volume = {98}, year = {2020}, month = {2020 Nov 01}, pages = {735-746D}, abstract = {Objective: To estimate the use of hospitals for four essential primary care services offered in health centres in low- and middle-income countries and to explore differences in quality between hospitals and health centres. Methods: We extracted data from all demographic and health surveys conducted since 2010 on the type of facilities used for obtaining contraceptives, routine antenatal care and care for minor childhood diarrhoea and cough or fever. Using mixed-effects logistic regression models we assessed associations between hospital use and individual and country-level covariates. We assessed competence of care based on the receipt of essential clinical actions during visits. We also analysed three indicators of user experience from countries with available service provision assessment survey data. Findings: On average across 56 countries, public hospitals were used as the sole source of care by 16.9\% of 126 012 women who obtained contraceptives, 23.1\% of 418 236 women who received routine antenatal care, 19.9\% of 47 677 children with diarrhoea and 18.5\% of 82 082 children with fever or cough. Hospital use was more common in richer countries with higher expenditures on health per capita and among urban residents and wealthier, better-educated women. Antenatal care quality was higher in hospitals in 44 countries. In a subset of eight countries, people using hospitals tended to spend more, report more problems and be somewhat less satisfied with the care received. Conclusion: As countries work towards achieving ambitious health goals, they will need to assess care quality and user preferences to deliver effective primary care services that people want to use.}, issn = {1564-0604}, doi = {10.2471/BLT.19.245563}, author = {Catherine Arsenault and Kim, Min Kyung and Aryal, Amit and Faye, Adama and Joseph, Jean Paul and Kassa, Munir and Degfie, Tizta Tilahun and Yahya, Talhiya and Margaret E Kruk} } @article {1396295, title = {The impact of continuous quality improvement on coverage of antenatal HIV care tests in rural South Africa: Results of a stepped-wedge cluster-randomised controlled implementation trial}, journal = {PLoS Med}, volume = {17}, year = {2020}, month = {2020 10}, pages = {e1003150}, abstract = {BACKGROUND: Evidence for the effectiveness of continuous quality improvement (CQI) in resource-poor settings is very limited. We aimed to establish the effects of CQI on quality of antenatal HIV care in primary care clinics in rural South Africa. METHODS AND FINDINGS: We conducted a stepped-wedge cluster-randomised controlled trial (RCT) comparing CQI to usual standard of antenatal care (ANC) in 7 nurse-led, public-sector primary care clinics-combined into 6 clusters-over 8 steps and 19 months. Clusters randomly switched from comparator to intervention on pre-specified dates until all had rolled over to the CQI intervention. Investigators and clusters were blinded to randomisation until 2 weeks prior to each step. The intervention was delivered by trained CQI mentors and included standard CQI tools (process maps, fishbone diagrams, run charts, Plan-Do-Study-Act [PDSA] cycles, and action learning sessions). CQI mentors worked with health workers, including nurses and HIV lay counsellors. The mentors used the standard CQI tools flexibly, tailored to local clinic needs. Health workers were the direct recipients of the intervention, whereas the ultimate beneficiaries were pregnant women attending ANC. Our 2 registered primary endpoints were viral load (VL) monitoring (which is critical for elimination of mother-to-child transmission of HIV [eMTCT] and the health of pregnant women living with HIV) and repeat HIV testing (which is necessary to identify and treat women who seroconvert during pregnancy). All pregnant women who attended their first antenatal visit at one of the 7 study clinics and were >=18 years old at delivery were eligible for endpoint assessment. We performed intention-to-treat (ITT) analyses using modified Poisson generalised linear mixed effects models. We estimated effect sizes with time-step fixed effects and clinic random effects (Model 1). In separate models, we added a nested random clinic-time step interaction term (Model 2) or individual random effects (Model 3). Between 15 July 2015 and 30 January 2017, 2,160 participants with 13,212 ANC visits (intervention n = 6,877, control n = 6,335) were eligible for ITT analysis. No adverse events were reported. Median age at first booking was 25 years (interquartile range [IQR] 21 to 30), and median parity was 1 (IQR 0 to 2). HIV prevalence was 47\% (95\% CI 42\% to 53\%). In Model 1, CQI significantly increased VL monitoring (relative risk [RR] 1.38, 95\% CI 1.21 to 1.57, p \< 0.001) but did not improve repeat HIV testing (RR 1.00, 95\% CI 0.88 to 1.13, p = 0.958). These results remained essentially the same in both Model 2 and Model 3. Limitations of our study include that we did not establish impact beyond the duration of the relatively short study period of 19 months, and that transition steps may have been too short to achieve the full potential impact of the CQI intervention. CONCLUSIONS: We found that CQI can be effective at increasing quality of primary care in rural Africa. Policy makers should consider CQI as a routine intervention to boost quality of primary care in rural African communities. Implementation research should accompany future CQI use to elucidate mechanisms of action and to identify factors supporting long-term success. TRIAL REGISTRATION: This trial is registered at ClinicalTrials.gov under registration number NCT02626351.}, keywords = {Adult, Anti-HIV Agents, Female, HIV Infections, HIV Seropositivity, Humans, Implementation Science, Infectious Disease Transmission, Vertical, Practice Patterns, Nurses{\textquoteright}, Pregnancy, Prenatal Care, Primary Health Care, Process Assessment, Health Care, Quality Improvement, Quality Indicators, Health Care, RNA, Viral, Rural Population, South Africa, Total Quality Management, Viral Load, Young Adult}, issn = {1549-1676}, doi = {10.1371/journal.pmed.1003150}, author = {Yapa, H Manisha and De Neve, Jan-Walter and Chetty, Terusha and Herbst, Carina and Post, Frank A and Jiamsakul, Awachana and Geldsetzer, Pascal and Harling, Guy and Dhlomo-Mphatswe, Wendy and Moshabela, Mosa and Matthews, Philippa and Ogbuoji, Osondu and Tanser, Frank and Gareta, Dickman and Herbst, Kobus and Pillay, Deenan and Wyke, Sally and B{\"a}rnighausen, Till} } @article {1396268, title = {Improving case detection of tuberculosis in hospitalised Kenyan children-employing the behaviour change wheel to aid intervention design and implementation}, journal = {Implement Sci}, volume = {15}, year = {2020}, month = {2020 Nov 25}, pages = {102}, abstract = {BACKGROUND: The true burden of tuberculosis in children remains unknown, but approximately 65\% go undetected each year. Guidelines for tuberculosis clinical decision-making are in place in Kenya, and the National Tuberculosis programme conducts several trainings on them yearly. By 2018, there were 183 GeneXpert{\textregistered} machines in Kenyan public hospitals. Despite these efforts, diagnostic tests are underused and there is observed under detection of tuberculosis in children. We describe the process of designing a contextually appropriate, theory-informed intervention to improve case detection of TB in children and implementation guided by the Behaviour Change Wheel. METHODS: We used an iterative process, going back and forth from quantitative and qualitative empiric data to reviewing literature, and applying the Behaviour Change Wheel guide. The key questions reflected on included (i) what is the problem we are trying to solve; (ii) what behaviours are we trying to change and in what way; (iii) what will it take to bring about desired change; (iv) what types of interventions are likely to bring about desired change; (v) what should be the specific intervention content and how should this be implemented? RESULTS: The following behaviour change intervention functions were identified as follows: (i) training: imparting practical skills; (ii) modelling: providing an example for people to aspire/imitate; (iii) persuasion: using communication to induce positive or negative feelings or stimulate action; (iv) environmental restructuring: changing the physical or social context; and (v) education: increasing knowledge or understanding. The process resulted in a multi-faceted intervention package composed of redesigning of child tuberculosis training; careful selection of champions; use of audit and feedback linked to group problem solving; and workflow restructuring with role specification. CONCLUSION: The intervention components were selected for their effectiveness (from literature), affordability, acceptability, and practicability and designed so that TB programme officers and hospital managers can be supported to implement them with relative ease, alongside their daily duties. This work contributes to the field of implementation science by utilising clear definitions and descriptions of underlying mechanisms of interventions that will guide others to do likewise in their settings for similar problems.}, issn = {1748-5908}, doi = {10.1186/s13012-020-01061-4}, author = {Oliwa, Jacquie Narotso and Nzinga, Jacinta and Masini, Enos and van Hensbroek, Micha{\"e}l Boele and Jones, Caroline and Mike English and Van{\textquoteright}t Hoog, Anja} } @article {1396251, title = {The Lancet Global Health Commission on High Quality Health Systems 1 year on: progress on a global imperative}, journal = {Lancet Glob Health}, volume = {8}, year = {2020}, month = {2020 01}, pages = {e30-e32}, keywords = {Global Health, Government Programs, Guidelines as Topic, Humans, Quality of Health Care}, issn = {2214-109X}, doi = {10.1016/S2214-109X(19)30485-1}, author = {Margaret E Kruk and Muhammad Pate} } @article {1396263, title = {Lessons from a Health Policy and Systems Research programme exploring the quality and coverage of newborn care in Kenya}, journal = {BMJ Glob Health}, volume = {5}, year = {2020}, month = {2020}, pages = {e001937}, abstract = {There are global calls for research to support health system strengthening in low-income and middle-income countries (LMICs). To examine the nature and magnitude of gaps in access and quality of inpatient neonatal care provided to a largely poor urban population, we combined multiple epidemiological and health services methodologies. Conducting this work and generating findings was made possible through extensive formal and informal stakeholder engagement linked to flexibility in the research approach while keeping overall goals in mind. We learnt that 45\% of sick newborns requiring hospital care in Nairobi probably do not access a suitable facility and that public hospitals provide 70\% of care accessed with private sector care either poor quality or very expensive. Direct observations of care and ethnographic work show that critical nursing workforce shortages prevent delivery of high-quality care in high volume, low-cost facilities and likely threaten patient safety and nurses{\textquoteright} well-being. In these challenging settings, routines and norms have evolved as collective coping strategies so health professionals maintain some sense of achievement in the face of impossible demands. Thus, the health system sustains a functional veneer that belies the stresses undermining quality, compassionate care. No one intervention will dramatically reduce neonatal mortality in this urban setting. In the short term, a substantial increase in the number of health workers, especially nurses, is required. This must be combined with longer term investment to address coverage gaps through redesign of services around functional tiers with improved information systems that support effective governance of public, private and not-for-profit sectors.}, keywords = {Health Policy, Health Services Accessibility, Hospitalization, Humans, Infant, Infant Care, Infant Mortality, Infant, Newborn, Infant, Newborn, Diseases, kenya, Quality of Health Care}, issn = {2059-7908}, doi = {10.1136/bmjgh-2019-001937}, author = {Mike English and Gathara, David and Nzinga, Jacinta and Kumar, Pratap and Were, Fred and Warfa, Osman and Tallam-Kimaiyo, Edna and Nandili, Mary and Obengo, Alfred and Abuya, Nancy and Jackson, Debra and Brownie, Sharon and Molyneux, Sassy and Jones, Caroline Olivia Holmes and Murphy, Georgina A V and McKnight, Jacob} } @article {1396289, title = {Parental satisfaction with quality of neonatal care in different level hospitals: evidence from Vietnam}, journal = {BMC Health Serv Res}, volume = {20}, year = {2020}, month = {2020 Mar 20}, pages = {238}, abstract = {BACKGROUND: Most health systems provide the most specialized, and presumably also the highest quality of care at a central level. This study assessed parental satisfaction and its determinants in the context of neonatal care in a provincial as well as a national hospital of Vietnam. METHODS: In this cross-sectional quantitative study, parents of 340 preterm infants admitted to neonatal care units of a national and a provincial hospital in 2018 were interviewed using structured questionnaires. Unadjusted and adjusted linear regression models were used to assess the relationship between parental satisfaction and hospital rank. RESULTS: The mean parental satisfaction score was 3.74 at the provincial, and 3.56 at the national hospital. These satisfaction differences persisted when parent and child characteristics were adjusted for in multivariate analysis. Longer length of stay and worsening infant health status were associated with parents reporting lower levels of satisfaction with the quality of care being provided at the healthcare facility. CONCLUSIONS: This study suggests that parents of preterm infants admitted in a provincial hospital were more satisfied with the quality of care received than those in a specialized national hospital. Length of stay and infant health status were the two most important determinants of level of parental satisfaction.}, keywords = {Cross-Sectional Studies, Female, Humans, Infant, Infant, Newborn, Infant, Premature, Intensive Care Units, Neonatal, Interviews as Topic, Male, Personal Satisfaction, Qualitative Research, Quality of Health Care, Vietnam}, issn = {1472-6963}, doi = {10.1186/s12913-020-5070-5}, author = {Nguyen, An Thi Binh and Nguyen, Ngan Thi Kim and Phan, Phuc Huu and van Eeuwijk, Peter and Fink, G{\"u}nther} } @article {1396271, title = {The politics and practice of initiating a public health postgraduate programme in three universities in sub-Saharan Africa: the challenges of alignment and coherence}, journal = {Int J Equity Health}, volume = {19}, year = {2020}, month = {2020 04 09}, pages = {52}, abstract = {BACKGROUND: In-country postgraduate training programme in low and middle income countries are widely considered to strengthen institutional and national capacity. There exists dearth of research about how new training initiatives in public health training institutions come about. This paper examines a south-south collaborative initiative wherein three universities based in Ethiopia, Rwanda and Mozambique set out to develop a local based postgraduate programme on health workforce development/management through partnership with a university in South Africa. METHODS: We used a qualitative case study design. We conducted semi-structured interviews with 36 key informants, who were purposively recruited based on their association or proximity to the programme, and their involvement in the development, review, approval and implementation of the programme. We gathered supplementary data through document reviews and observation. Thematic analysis was used and themes were generated inductively from the data and deductively from literature on capacity development. RESULTS: University A successfully initiated a postgraduate training programme in health workforce development/management. University B and C faced multiple challenges to embed the programme. It was evident that multiple actors underpin programme introduction across institutions, characterized by contestations over issues of programme feasibility, relevance, or need. A daunting challenge in this regard is establishing coherence between health ministries{\textquoteright} expectation to roll out training programmes that meet national health priorities and ensure sustainability, and universities and academics{\textquoteright} expectations for investment or financial incentive. Programme champions, located in the universities, can be key actors in building such coherence, if they are committed and received sustained support. The south-south initiative also suffers from lack of long term and adequate support. CONCLUSIONS: Against the background of very limited human capacity and competition for this capacity, initiating the postgraduate programme on health workforce development/management proved to be a political as much as a technical undertaking influenced by multiple actors vying for recognition or benefits, and influence over issues of programme feasibility, relevance or need. Critical in the success of the initiative was alignment and coherence among actors, health ministries and universities in particular, and how well programme champions are able to garner support for and ownership of programme locally. The paper argues that coherence and alignment are crucial to embed programmes, yet hard to achieve when capacity and resources are limited and contested.}, keywords = {Adult, Capacity Building, Curriculum, Education, Medical, Graduate, Ethiopia, Female, Health Facility Administration, Humans, Male, Mozambique, Politics, Public Health, Qualitative Research, Rwanda, Universities, Young Adult}, issn = {1475-9276}, doi = {10.1186/s12939-020-01163-x}, author = {Amde, Woldekidan Kifle and Sanders, David and Sidat, Mohsin and Nzayirambaho, Manasse and Haile-Mariam, Damen and Lehmann, Uta} } @article {1396282, title = {Quality antenatal care services delivery at health facilities of Ethiopia, assessment of the structure/input of care setting}, journal = {BMC Health Serv Res}, volume = {20}, year = {2020}, month = {2020 Jun 01}, pages = {485}, abstract = {BACKGROUND: According to the Donabedian model, the assessment for the quality of care includes three dimensions. These are structure, process, and outcome. Therefore, the present study aimed at assessing the structural quality of Antenatal care (ANC) service provision in Ethiopian health facilities. METHODS: Data were obtained from the 2018 Ethiopian Service Availability and Readiness Assessment (SARA) survey. The SARA was a cross-sectional facility-based assessment conducted to capture health facility service availability and readiness in Ethiopia. A total of 764 health facilities were sampled in the 9 regions and 2 city administrations of the country. The availability of equipment, supplies, medicine, health worker{\textquoteright}s training and availability of guidelines were assessed. Data were collected from October-December 2017. We run a multiple linear regression model to identify predictors of health facility readiness for Antenatal care service. The level of significance was determined at a p-value \< 0.05. RESULT: Among the selected health facilities, 80.5\% of them offered Antenatal care service. However, the availability of specific services was very low. The availability of tetanus toxoid vaccination, folic acid, iron supplementation, and monitoring of hypertension disorder was, 67.7, 65.6, 68.6, and 75.1\%, respectively. The overall mean availability among the ten tracer items that are necessary to provide quality Antenatal care services was 50\%. In the multiple linear regression model, health centers, health posts and clinics scored lower Antenatal care service readiness compared to hospitals. The overall readiness index score was lower for private health facilities (β = - 0.047, 95\% CI: (- 0.1, - 0.004). The readiness score had no association with the facility settings (Urban/Rural) (p-value \> 0.05). Facilities in six regions except Dire Dawa\ had (β = 0.067, 95\% CI: (0.004, 0.129) lower readiness score than facilities in Tigray region (p-value \< 0.015). CONCLUSION: This analysis provides evidence of the gaps in structural readiness of health facilities to provide quality Antenatal care services. Key and essential supplies for quality Antenatal care service provision were missed in many of the health facilities. Guaranteeing properly equipped and staffed facilities shall be a target to improve the quality of Antenatal care services provision.}, keywords = {Cross-Sectional Studies, Ethiopia, Female, Health Facilities, Health Facility Administration, Health Services Accessibility, Humans, Pregnancy, Prenatal Care, Quality of Health Care, Surveys and Questionnaires}, issn = {1472-6963}, doi = {10.1186/s12913-020-05372-6}, author = {Defar, Atkure and Getachew, Theodros and Taye, Girum and Tadele, Tefera and Getnet, Misrak and Shumet, Tigist and Molla, Gebeyaw and Gonfa, Geremew and Teklie, Habtamu and Tadesse, Ambaye and Bekele, Abebe} } @article {1396291, title = {Quality of clinical management of children diagnosed with malaria: A cross-sectional assessment in 9 sub-Saharan African countries between 2007-2018}, journal = {PLoS Med}, volume = {17}, year = {2020}, month = {2020 09}, pages = {e1003254}, abstract = {BACKGROUND: Appropriate clinical management of malaria in children is critical for preventing progression to severe disease and for reducing the continued high burden of malaria mortality. This study aimed to assess the quality of care provided to children under 5 diagnosed with malaria across 9 sub-Saharan African countries. METHODS AND FINDINGS: We used data from the Service Provision Assessment (SPA) survey. SPAs are nationally representative facility surveys capturing quality of sick-child care, facility readiness, and provider and patient characteristics. The data set contained 24,756 direct clinical observations of outpatient sick-child visits across 9 countries, including Uganda (2007), Rwanda (2007), Namibia (2009), Kenya (2010), Malawi (2013), Senegal (2013-2017), Ethiopia (2014), Tanzania (2015), and Democratic Republic of the Congo (2018). We assessed the proportion of children with a malaria diagnosis who received a blood test diagnosis and an appropriate antimalarial. We used multilevel logistic regression to assess facility and provider and patient characteristics associated with these outcomes. Subgroup analyses with the 2013-2018 country surveys only were conducted for all outcomes. Children observed were on average 20.5 months old and were most commonly diagnosed with respiratory infection (47.7\%), malaria (29.7\%), and/or gastrointestinal infection (19.7\%). Among the 7,340 children with a malaria diagnosis, 32.5\% (95\% CI: 30.3\%-34.7\%) received both a blood-test-based diagnosis and an appropriate antimalarial. The proportion of children with a blood test diagnosis and an appropriate antimalarial ranged from 3.4\% to 57.1\% across countries. In the more recent surveys (2013-2018), 40.7\% (95\% CI: 37.7\%-43.6\%) of children with a malaria diagnosis received both a blood test diagnosis and appropriate antimalarial. Roughly 20\% of children diagnosed with malaria received no antimalarial at all, and nearly 10\% received oral artemisinin monotherapy, which is not recommended because of concerns regarding parasite resistance. Receipt of a blood test diagnosis and appropriate antimalarial was positively correlated with being seen at a facility with diagnostic equipment in stock (adjusted OR 3.67; 95\% CI: 2.72-4.95) and, in the 2013-2018 subsample, with being seen at a facility with Artemisinin Combination Therapies (ACTs) in stock (adjusted OR 1.60; 95\% CI:1.04-2.46). However, even if all children diagnosed with malaria were seen by a trained provider at a facility with diagnostics and medicines in stock, only a predicted 37.2\% (95\% CI: 34.2\%-40.1\%) would have received a blood test and appropriate antimalarial (44.4\% for the 2013-2018 subsample). Study limitations include the lack of confirmed malaria test results for most survey years, the inability to distinguish between a diagnosis of uncomplicated or severe malaria, the absence of other relevant indicators of quality of care including dosing and examinations, and that only 9 countries were studied. CONCLUSIONS: In this study, we found that a majority of children diagnosed with malaria across the 9 surveyed sub-Saharan African countries did not receive recommended care. Clinical management is positively correlated with the stocking of essential commodities and is somewhat improved in more recent years, but important quality gaps remain in the countries studied. Continued reductions in malaria mortality will require a bigger push toward quality improvements in clinical care.}, keywords = {Africa South of the Sahara, Antimalarials, Child, Child, Preschool, Cross-Sectional Studies, Delivery of Health Care, Diagnostic Tests, Routine, Female, Humans, Infant, Malaria, Male, Quality of Health Care}, issn = {1549-1676}, doi = {10.1371/journal.pmed.1003254}, author = {Cohen, Jessica L and Leslie, Hannah H and Saran, Indrani and Fink, G{\"u}nther} } @article {1396290, title = {Results-based financing to increase uptake of skilled delivery services in The Gambia: using the {\textquoteright}three delays{\textquoteright} model to interpret midline evaluation findings}, journal = {BMC Pregnancy Childbirth}, volume = {20}, year = {2020}, month = {2020 Nov 23}, pages = {712}, abstract = {BACKGROUND: Delays in accessing skilled delivery services are a major contributor to high maternal mortality in resource-limited settings. In 2015, the government of The Gambia initiated a results-based financing intervention that sought to increase uptake of skilled delivery. We performed a midline evaluation to determine the impact of the intervention and explore causes of delays. METHODS: A mixed methods design was used to measure changes in uptake of skilled delivery and explore underlying reasons, with communities randomly assigned to four arms: (1) community-based intervention, (2) facility-based intervention, (3) community- and facility-based intervention, and (4) control. We obtained quantitative data from household surveys conducted at baseline (n = 1423) and midline (n = 1573). Qualitative data came from semi-structured interviews (baseline n = 20; midline n = 20) and focus group discussions (baseline n = 27; midline n = 39) with a range of stakeholders. Multivariable linear regression models were estimated using pooled data from baseline and midline. Qualitative data were recorded, transcribed, translated and thematically analyzed. RESULTS: No increase was found in uptake of skilled delivery services between baseline and midline. However, relative to the control group, significant increases in referral to health facilities for delivery were found in areas receiving the community-based intervention (beta = 0.078, p \< 0.10) and areas receiving both the community-based and facility-based interventions (beta = 0.198, p \< 0.05). There was also an increase in accompaniment to health facilities for delivery in areas receiving only community-based interventions (beta = 0.095, p \< 0.05). Transportation to health facilities for delivery increased in areas with both interventions (beta = 0.102, p \< 0.05). Qualitative data indicate that delays in the decision to seek institutional delivery usually occurred when women had limited knowledge of delivery indications. Delays in reaching a health facility typically occurred due to transportation-related challenges. Although health workers noted shortages in supplies and equipment, women reported being supported by staff and experiencing minimal delays in receiving skilled delivery care once at the facility. CONCLUSIONS: Focusing efforts on informing the decision to seek care and overcoming transportation barriers can reduce delays in care-seeking among pregnant women and facilitate efforts to increase uptake of skilled delivery services through results-based financing mechanisms.}, issn = {1471-2393}, doi = {10.1186/s12884-020-03387-9}, author = {Ferguson, Laura and Hasan, Rifat and Boudreaux, Chantelle and Thomas, Hannah and Jallow, Mariama and Fink, G{\"u}nther and Project Implementation Committee (PIC)} } @article {1396265, title = {Shocks, stress and everyday health system resilience: experiences from the Kenyan coast}, journal = {Health Policy Plan}, volume = {35}, year = {2020}, month = {2020 Jun 01}, pages = {522-535}, abstract = {Health systems are faced with a wide variety of challenges. As complex adaptive systems, they respond differently and sometimes in unexpected ways to these challenges. We set out to examine the challenges experienced by the health system at a sub-national level in Kenya, a country that has recently undergone rapid devolution, using an {\textquoteright}everyday resilience{\textquoteright} lens. We focussed on chronic stressors, rather than acute shocks in examining the responses and organizational capacities underpinning those responses, with a view to contributing to the understanding of health system resilience. We drew on learning and experiences gained through working with managers using a learning site approach over the years. We also collected in-depth qualitative data through informal observations, reflective meetings and in-depth interviews with middle-level managers (sub-county and hospital) and peripheral facility managers (n = 29). We analysed the data using a framework approach. Health managers reported a wide range of health system stressors related to resource scarcity, lack of clarity in roles and political interference, reduced autonomy and human resource management. The health managers adopted absorptive, adaptive and transformative strategies but with mixed effects on system functioning. Everyday resilience seemed to emerge from strategies enacted by managers drawing on a varying combination of organizational capacities depending on the stressor and context.}, keywords = {Delivery of Health Care, Government Programs, Health Planning Organizations, Health Resources, Hospital Administration, Humans, kenya, Politics, Workforce}, issn = {1460-2237}, doi = {10.1093/heapol/czaa002}, author = {Kagwanja, Nancy and Waithaka, Dennis and Nzinga, Jacinta and Tsofa, Benjamin and Boga, Mwanamvua and Leli, Hassan and Mataza, Christine and Gilson, Lucy and Molyneux, Sassy and Barasa, Edwine} } @article {1396264, title = {Systems and implementation science should be part of the COVID-19 response in low resource settings}, journal = {BMC Med}, volume = {18}, year = {2020}, month = {2020 07 15}, pages = {219}, issn = {1741-7015}, doi = {10.1186/s12916-020-01696-6}, author = {Mike English and Moshabela, Mosa and Nzinga, Jacinta and Barasa, Edwine and Tsofa, Benjamin and Marchal, Bruno and Margaret E Kruk} } @article {1396307, title = {Transformational improvement in quality care and health systems: the next decade}, journal = {BMC Med}, volume = {18}, year = {2020}, month = {2020 10 29}, pages = {340}, abstract = {BACKGROUND: Healthcare is amongst the most complex of human systems. Coordinating activities and integrating newer with older ways of treating patients while delivering high-quality, safe care, is challenging. Three landmark reports in 2018 led by (1) the Lancet Global Health Commission, (2) a coalition of the World Health Organization, the Organisation for Economic Co-operation and Development and the World Bank, and (3) the National Academies of Sciences, Engineering and Medicine of the United States propose that health systems need to tackle care quality, create less harm and provide universal health coverage in all nations, but especially low- and middle-income countries. The objective of this study is to review these reports with the aim of advancing the discussion beyond a conceptual diagnosis of quality gaps into identification of practical opportunities for transforming health systems by 2030. MAIN BODY: We analysed the reports via text-mining techniques and content analyses to derive their key themes and concepts. Initiatives to make progress include better measurement, using the capacities of information and communications technologies, taking a systems view of change, supporting systems to be constantly improving, creating learning health systems and undergirding progress with effective research and evaluation. Our analysis suggests that the world needs to move from 2018, the year of reports, to the 2020s, the decade of action. We propose three initiatives to support this move: first, developing a blueprint for change, modifiable to each country{\textquoteright}s circumstances, to give effect to the reports{\textquoteright} recommendations; second, to make tangible steps to reduce inequities within and across health systems, including redistributing resources to areas of greatest need; and third, learning from what goes right to complement current efforts focused on reducing things going wrong. We provide examples of targeted funding which would have major benefits, reduce inequalities, promote universality and be better at learning from successes as well as failures. CONCLUSION: The reports contain many recommendations, but lack an integrated, implementable, 10-year action plan for the next decade to give effect to their aims to improve care to the most vulnerable, save lives by providing high-quality healthcare and shift to measuring and ensuring better systems- and patient-level outcomes. This article signals what needs to be done to achieve these aims.}, keywords = {Delivery of Health Care, Humans, Quality of Health Care}, issn = {1741-7015}, doi = {10.1186/s12916-020-01739-y}, author = {Braithwaite, Jeffrey and Vincent, Charles and Garcia-Elorrio, Ezequiel and Imanaka, Yuichi and Nicklin, Wendy and Sodzi-Tettey, Sodzi and Bates, David W} } @article {1396280, title = {Triangulating data sources for further learning from and about the MDSR in Ethiopia: a cross-sectional review of facility based maternal death data from EmONC assessment and MDSR system}, journal = {BMC Pregnancy Childbirth}, volume = {20}, year = {2020}, month = {2020 Apr 09}, pages = {206}, abstract = {BACKGROUND: Triangulating findings from MDSR with other sources can better inform maternal health programs. A national Emergency Obstetric and Newborn Care (EmONC) assessment and the Maternal Death Surveillance and Response (MDSR) system provided data to determine the coverage of MDSR implementation in health facilities, the leading causes and contributing factors to death, and the extent to which life-saving interventions were provided to deceased women. METHODS: This paper is based on triangulation of findings from a descriptive analysis of secondary data extracted from the 2016 EmONC assessment and the MDSR system databases. EmONC assessment was conducted in 3804 health facilities. Data from interview of each facility leader on MDSR implementation, review of 1305 registered maternal deaths and 679 chart reviews of maternal deaths that happened form May 16, 2015 to December 15, 2016 were included from the EmONC assessment. Case summary reports of 601 reviewed maternal deaths were included from the MDSR system. RESULTS: A maternal death review committee was established in 64\% of health facilities. 5.5\% of facilities had submitted at least one maternal death summary report to the national MDSR database. Postpartum hemorrhage (10-27\%) and severe preeclampsia/eclampsia (10-24.1\%) were the leading primary causes of maternal death. In MDSR, delay-1 factors contributed to 7-33\% of maternal deaths. Delay-2, related to reaching a facility, contributed to 32\% \& 40\% of maternal deaths in the EmONC assessment and MDSR, respectively. Similarly, delay-3 factor due to delayed transfer of mothers to appropriate level of care contributed for 29 and 22\% of maternal deaths. From the EmONC data, 72\% of the women who died due to severe pre-eclampsia or eclampsia were given anticonvulsants while 48\% of those dying of postpartum haemorrhage received uterotonics. CONCLUSION: The facility level implementation coverage of MDSR was sub-optimal. Obstetric hemorrhage and severe preeclampsia or eclampsia were the leading causes of maternal death. Delayed arrival to facility (Delay 2) was the predominant contributing factor to facility-based maternal deaths. The limited EmONC provision should be the focus of quality improvement in health facilities.}, keywords = {Cause of Death, Cross-Sectional Studies, Ethiopia, Female, Health Facilities, Humans, Information Storage and Retrieval, Maternal Death, Maternal Mortality, Pregnancy, Pregnancy Complications}, issn = {1471-2393}, doi = {10.1186/s12884-020-02899-8}, author = {Hadush, Azmach and Dagnaw, Ftalew and Getachew, Theodros and Bailey, Patricia E and Lawley, Ruth and Ruano, Ana Lorena} } @article {1394571, title = {The Lancet Global Health Commission on High Quality Health Systems: countries are seizing the quality agenda}, journal = {Journal of Global Health Science}, year = {2019}, url = {https://e-jghs.org/DOIx.php?id=10.35500/jghs.2019.1.e43}, author = {Todd P. Lewis and Margaret E Kruk} } @article {1396279, title = {Antenatal care use in Ethiopia: a spatial and multilevel analysis}, journal = {BMC Pregnancy Childbirth}, volume = {19}, year = {2019}, month = {2019 Nov 01}, pages = {399}, abstract = {BACKGROUND: Accessibility and utilization of antenatal care (ANC) service varies depending on different geographical locations, sociodemographic characteristics, political and other factors. A geographically linked data analysis using population and health facility data is valuable to map ANC use, and identify inequalities in service access and provision. Thus, this study aimed to assess the spatial patterns of ANC use, and to identify associated factors among pregnant women in Ethiopia. METHOD: A secondary data analysis of the 2016 Ethiopia Demographic and Health Survey linked with the 2014 Ethiopian Service Provision Assessment was conducted. A multilevel analysis was carried out using the SAS GLIMMIX procedure. Furthermore, hot spot analysis and spatial regressions were carried out to identify the hot spot areas of and factors associated with the spatial variations in ANC use using ArcGIS and R softwares. RESULTS: A one-unit increase in the mean score of ANC service availability in a typical region was associated with a five-fold increase in the odds of having more ANC visits. Moreover, every one-kilometre increase in distance to the nearest ANC facility in a typical region was negatively associated with having at least four ANC visits. Twenty-five percent of the variability in having at least four ANC visits was accounted for by region of living. The spatial analysis found that the Southern Nations, Nationalities and Peoples region had high clusters of at least four ANC visits. Furthermore, the coefficients of having the first ANC visit during the first trimester were estimated to have spatial variations in the use of at least four ANC visits. CONCLUSION: There were significant variations in the use of ANC services across the different regions of Ethiopia. Region of living and distance were key drivers of ANC use underscoring the need for increased ANC availability, particularly in the cold spot regions.}, keywords = {Adolescent, Adult, demography, Ethiopia, Facilities and Services Utilization, Female, Geography, Health Facilities, Health Services Accessibility, Healthcare Disparities, Humans, Multilevel Analysis, Patient Acceptance of Health Care, Pregnancy, Prenatal Care, Socioeconomic Factors, spatial analysis, Young Adult}, issn = {1471-2393}, doi = {10.1186/s12884-019-2550-x}, author = {Tegegne, Teketo Kassaw and Chojenta, Catherine and Getachew, Theodros and Smith, Roger and Loxton, Deborah} } @article {1396317, title = {The catalytic role of a research university and international partnerships in building research capacity in Peru: A bibliometric analysis}, journal = {PLoS Negl Trop Dis}, volume = {13}, year = {2019}, month = {2019 07}, pages = {e0007483}, abstract = {OBJECTIVE: In Peru, the past three decades have witnessed impressive growth in biomedical research catalyzed from a single research university and its investigators who secured international partnerships and funding. We conducted a bibliometric analysis of publications by Peruvian authors to understand the roots of this growth and the spread of research networks within the country. METHODS: For 1997-2016, publications from Web of Science with at least one author affiliated with a Peruvian institution were examined by year, author affiliations, funding agencies, co-authorship linkages, and research topics. RESULTS: From 1997-2016, the annual number of publications from Peru increased 9-fold from 75 to 672 totaling 6032. Of these, 56\% of the articles had co-authors from the US, 13\% from the UK, 12\% from Brazil, and 10\% from Spain. Universidad Peruana Cayetano Heredia (UPCH) was clearly the lead research institution noted on one-third of publications. Of the 20 most published authors, 15 were Peruvians, 14 trained at some point at UPCH, and 13 received advanced training abroad. Plotting co-authorships documented the growth of institutional collaborations, the robust links between investigators and some lineages of mentorship. CONCLUSIONS: This analysis suggests that international training of Peruvian physician-scientists who built and sustained longstanding international partnerships with funding accelerated quality research on diseases of local importance. The role of a single research university, UPCH, was critical to advance a culture of biomedical research. Increased funding from the Peruvian Government and its Council for Science, Technology and Innovation will be needed to sustain this growth in the future. Middle-income countries might consider the Peruvian experience where long-term research and training partnerships yielded impressive advances to address key health priorities of the country.}, keywords = {Academies and Institutes, Authorship, Awards and Prizes, Bibliometrics, Biomedical Research, Capacity Building, Databases, Bibliographic, History, 20th Century, History, 21st Century, Humans, International Cooperation, Peru, Publications, Publishing, Research Design, Research Personnel, Universities}, issn = {1935-2735}, doi = {10.1371/journal.pntd.0007483}, author = {Belter, Christopher W and Garcia, Patricia J and Livinski, Alicia A and Leon-Velarde, Fabiola and Weymouth, Kristen H and Glass, Roger I} } @article {1396877, title = {Clinical performance among recent graduates in nine low- and middle-income countries}, journal = {Trop Med Int Health}, volume = {24}, year = {2019}, month = {2019 05}, pages = {620-635}, abstract = {OBJECTIVES: Recent studies have identified large and systematic deficits in clinical care in low-income countries that are likely to limit health gains. This has focused attention on effectiveness of pre-service education. One approach to assessing this is observation of clinical performance among recent graduates providing care. However, no studies have assessed performance in a standard manner across countries. We analysed clinical performance among recently graduated providers in nine low- or middle-income countries. METHODS: Service Provision Assessments from Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Tanzania, and Uganda were used. We constructed a Good Medical Practice Index that assesses completion of essential clinical actions using direct observations of care (range 0-1), calculated index scores by country and clinical cadre, and assessed the role of facility and clinical characteristics using regression analysis. RESULTS: Our sample consisted of 2223 clinicians with at least one observation of care. The Good Medical Practice score for the sample was 0.50 (SD = 0.20). Nurses and midwives had the highest score at 0.57 (SD = 0.20), followed by associate clinicians at 0.43 (SD = 0.18), and physicians at 0.42 (SD = 0.16). The average national performance varied from 0.63 (SD = 0.18) in Uganda to 0.39 (SD = 0.17) in Nepal, persisting after adjustment for facility and clinician characteristics. CONCLUSIONS: These results show substantial gaps in clinical performance among recently graduated clinicians, raising concerns about models of clinical education. Competency-based education should be considered to improve quality of care in LMICs. Observations of care offer important insight into the quality of clinical education.}, keywords = {Adult, Africa, Child, Child, Preschool, Clinical Competence, Delivery of Health Care, Developing Countries, Education, Medical, Female, Haiti, Health Care Surveys, Humans, Income, Infant, Infant, Newborn, Male, Maternal-Child Health Services, Midwifery, Nepal, Nurses, Physicians, Pregnancy, Quality of Health Care}, issn = {1365-3156}, doi = {10.1111/tmi.13224}, author = {Lewis, Todd P and Sanam Roder-DeWan and Address Malata and Youssoupha Ndiaye and Margaret E Kruk} } @article {1396316, title = {Conceptual Framework of Mentoring in Low- and Middle-Income Countries to Advance Global Health}, journal = {Am J Trop Med Hyg}, volume = {100}, year = {2019}, month = {2019 01}, pages = {9-14}, abstract = {Although mentoring is not a common practice in low- and middle-income countries (LMICs), there is a strong need for it. Conceptual frameworks provide the structure to design, study, and problem-solve complex phenomena. Following four workshops in South America, Asia, and Africa, and borrowing on theoretical models from higher education, this article proposes two conceptual frameworks of mentoring in LMICs. In the first model, we propose to focus the mentor-mentee relationship and interactions, and in the second, we look at mentoring activities from a mentees{\textquoteright} perspective. Our models emphasize the importance of an ongoing dynamic between the mentor and mentee that is mutually beneficial. It also emphasizes the need for institutions to create enabling environments that encourage mentorship. We expect that these frameworks will help LMIC institutions to design new mentoring programs, clarify expectations, and analyze problems with existing mentoring programs. Our models, while being framed in the context of global health, have the potential for wider application geographically and across disciplines.}, keywords = {Africa, Asia, Biomedical Research, Cross-Cultural Comparison, Developing Countries, education, Global Health, Humans, Mentoring, Mentors, South America, Teaching}, issn = {1476-1645}, doi = {10.4269/ajtmh.18-0557}, author = {Prasad, Shailendra and Sopdie, Elizabeth and Meya, David and Kalbarczyk, Anna and Garcia, Patricia J} } @article {1396286, title = {Delivering quality: safe childbirth requires more than facilities}, journal = {Lancet Glob Health}, volume = {7}, year = {2019}, month = {2019 08}, pages = {e990-e991}, keywords = {Delivery, Obstetric, Female, Ghana, Humans, Parturition, Perinatal Death, Perinatal Mortality, Pregnancy}, issn = {2214-109X}, doi = {10.1016/S2214-109X(19)30193-7}, author = {Fink, G{\"u}nther and Cohen, Jessica} } @article {1396311, title = {The effectiveness of the quality improvement collaborative strategy in low- and middle-income countries: A systematic review and meta-analysis}, journal = {PLoS One}, volume = {14}, year = {2019}, month = {2019}, pages = {e0221919}, abstract = {BACKGROUND: Quality improvement collaboratives (QICs) have been used to improve health care for decades. Evidence on QIC effectiveness has been reported, but systematic reviews to date have little information from low- and middle-income countries (LMICs). OBJECTIVE: To assess the effectiveness of QICs in LMICs. METHODS: We conducted a systematic review following Cochrane methods, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach for quality of evidence grading, and the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement for reporting. We searched published and unpublished studies between 1969 and March 2019 from LMICs. We included papers that compared usual practice with QICs alone or combined with other interventions. Pairs of reviewers independently selected and assessed the risk of bias and extracted data of included studies. To estimate strategy effectiveness from a single study comparison, we used the median effect size (MES) in the comparison for outcomes in the same outcome group. The primary analysis evaluated each strategy group with a weighted median and interquartile range (IQR) of MES values. In secondary analyses, standard random-effects meta-analysis was used to estimate the weighted mean MES and 95\% confidence interval (CI) of the mean MES of each strategy group. This review is registered with PROSPERO (International Prospective Register of Systematic Reviews): CRD42017078108. RESULTS: Twenty-nine studies were included; most (21/29, 72.4\%) were interrupted time series studies. Evidence quality was generally low to very low. Among studies involving health facility-based health care providers (HCPs), for "QIC only", effectiveness varied widely across outcome groups and tended to have little effect for patient health outcomes (median MES less than 2 percentage points for percentage and continuous outcomes). For "QIC plus training", effectiveness might be very high for patient health outcomes (for continuous outcomes, median MES 111.6 percentage points, range: 96.0 to 127.1) and HCP practice outcomes (median MES 52.4 to 63.4 percentage points for continuous and percentage outcomes, respectively). The only study of lay HCPs, which used "QIC plus training", showed no effect on patient care-seeking behaviors (MES -0.9 percentage points), moderate effects on non-care-seeking patient behaviors (MES 18.7 percentage points), and very large effects on HCP practice outcomes (MES 50.4 percentage points). CONCLUSIONS: The effectiveness of QICs varied considerably in LMICs. QICs combined with other invention components, such as training, tended to be more effective than QICs alone. The low evidence quality and large effect sizes for QIC plus training justify additional high-quality studies assessing this approach in LMICs.}, keywords = {Delivery of Health Care, Developing Countries, Health Personnel, Humans, Poverty, Quality Improvement}, issn = {1932-6203}, doi = {10.1371/journal.pone.0221919}, author = {Garcia-Elorrio, Ezequiel and Rowe, Samantha Y and Teijeiro, Maria E and Ciapponi, Agust{\'\i}n and Alexander K Rowe} } @article {1396267, title = {Exploring the space for task shifting to support nursing on neonatal wards in Kenyan public hospitals}, journal = {Hum Resour Health}, volume = {17}, year = {2019}, month = {2019 03 06}, pages = {18}, abstract = {BACKGROUND: Nursing practice is a key driver of quality care and can influence newborn health outcomes where nurses are the primary care givers to this highly dependent group. However, in sub-Saharan Africa, nursing work environments are characterized by heavy workloads, insufficient staffing and regular medical emergencies, which compromise the ability of nurses to provide quality care. Task shifting has been promoted as one strategy for making efficient use of human resources and addressing these issues. AIMS AND OBJECTIVES: We aimed to understand the nature and practice of neonatal nursing in public hospitals in Nairobi so as to determine what prospect there might be for relieving pressure by shifting nurses{\textquoteright} work to others. METHODS: This paper is based on an 18-month qualitative study of three newborn units of three public hospitals-all located in Nairobi county-using an ethnographic approach. We draw upon a mix of 32 interviews, over 250 h{\textquoteright} observations, field notes and informal conversations. Data were collected from senior nursing experts in newborn nursing, neonatal nurse in-charges, neonatal nurses, nursing students and support staff. RESULTS: To cope with difficult work conditions characterized by resource challenges and competing priorities, nurses have developed a ritualized schedule and a form of {\textquoteright}subconscious triage{\textquoteright}. Informal, organic task shifting was already taking place whereby particular nursing tasks were delegated to students, mothers and support staff, often without any structured supervision. Despite this practice, nurses were agnostic about formal institutionalization of task shifting due to concerns around professional boundaries and the practicality of integrating a new cadre into an already stressed health system. CONCLUSION: Our findings revealed a routine template of neonatal nursing work which nurses used to control unpredictability. We found that this model of nursing encouraged delegation of less technical tasks to subordinates, parents and other staff through the process of {\textquoteright}subconscious triage{\textquoteright}. The rich insights we gained from this organic form of task shifting can inform more formal task-shifting projects as they seek to identify tasks most easily delegated, and how best to support and work with busy nurses.}, keywords = {Adaptation, Psychological, Attitude of Health Personnel, Delivery of Health Care, Hospital Departments, Hospitals, Public, Humans, Infant Care, Infant, Newborn, kenya, Models, Nursing, Nurses, Nursing Assistants, Nursing Staff, Hospital, Parents, Pediatric Nursing, Professional Role, Qualitative Research, Quality of Health Care, Surveys and Questionnaires, Unconscious, Psychology, Workload, Workplace}, issn = {1478-4491}, doi = {10.1186/s12960-019-0352-x}, author = {Nzinga, Jacinta and McKnight, Jacob and Jepkosgei, Joyline and Mike English} } @article {1396301, title = {Hospital-based quality improvement interventions for patients with heart failure: a systematic review}, journal = {Heart}, volume = {105}, year = {2019}, month = {2019 03}, pages = {431-438}, abstract = {OBJECTIVE: To estimate the direction and magnitude of effect and quality of evidence for hospital-based heart failure (HF) quality improvement interventions on process of care measures and clinical outcomes among patients with acute HF. REVIEW METHODS: We performed a structured search to identify relevant randomised trials evaluating the effect of in-hospital quality improvement interventions for patients hospitalised with HF through February 2017. Studies were independently reviewed in duplicate for key characteristics, outcomes were summarised and a qualitative synthesis was performed due to substantial heterogeneity. RESULTS: From 3615 records, 14 randomised controlled trials were identified for inclusion with multifaceted interventions. There was a trend towards higher in-hospital use of ACE inhibitors (ACE-I; 57.9\%vs40.0\%) and beta-blockers (BBs; 46.7\%vs10.2\%) in the intervention than the comparator in one trial (n=429 participants). Five trials (n=78 727 participants) demonstrated no effect of the intervention on use of ACE-I or angiotensin receptor blocker at discharge. Three trials (n=89 660 participants) reported no effect on use of BB at discharge. Two trials (n=419 participants) demonstrated a trend towards lower hospital readmission up to 90 days after discharge. There was no consistent effect of the quality improvement intervention on 30-day all-cause mortality, hospital length of stay and patient-level health-related quality of life. CONCLUSIONS: Randomised trials of hospital-based HF quality improvement interventions do not show a consistent effect on most process of care measures and clinical outcomes. The overall quality of evidence for the prespecified primary and key secondary outcomes was very low to moderate, suggesting that future research will likely influence these estimates. TRIAL REGISTRATION NUMBER: CRD42016049545.}, keywords = {Heart Failure, Hospitalization, Humans, Outcome Assessment, Health Care, Patient Care Management, Quality Improvement, Quality of Life, Randomized Controlled Trials as Topic}, issn = {1468-201X}, doi = {10.1136/heartjnl-2018-314129}, author = {Agarwal, Anubha and Bahiru, Ehete and Yoo, Sang Gune Kyle and Berendsen, Mark A and Harikrishnan, Sivadasanpillai and Hernandez, Adrian F and Prabhakaran, Dorairaj and Huffman, Mark D} } @article {1396269, title = {Hybrid clinical-managers in Kenyan hospitals}, journal = {J Health Organ Manag}, volume = {33}, year = {2019}, month = {2019 Mar 28}, pages = {173-187}, abstract = {PURPOSE: The purpose of this paper is to explore the way "hybrid" clinical managers in Kenyan public hospitals interpret and enact hybrid clinical managerial roles in complex healthcare settings affected by professional, managerial and practical norms. DESIGN/METHODOLOGY/APPROACH: The authors conducted a case study of two Kenyan district hospitals, involving repeated interviews with eight mid-level clinical managers complemented by interviews with 51 frontline workers and 6 senior managers, and 480 h of ethnographic field observations. The authors analysed and theorised data by combining inductive and deductive approaches in an iterative cycle. FINDINGS: Kenyan hybrid clinical managers were unprepared for managerial roles and mostly reluctant to do them. Therefore, hybrids{\textquoteright} understandings and enactment of their roles was determined by strong professional norms, official hospital management norms (perceived to be dysfunctional and unsupportive) and local practical norms developed in response to this context. To navigate the tensions between managerial and clinical roles in the absence of management skills and effective structures, hybrids drew meaning from clinical roles, navigating tensions using prevailing routines and unofficial practical norms. PRACTICAL IMPLICATIONS: Understanding hybrids{\textquoteright} interpretation and enactment of their roles is shaped by context and social norms and this is vital in determining the future development of health system{\textquoteright}s leadership and governance. Thus, healthcare reforms or efforts aimed towards increasing compliance of public servants have little influence on behaviour of key actors because they fail to address or acknowledge the norms affecting behaviours in practice. The authors suggest that a key skill for clinical managers in managers in low- and middle-income country (LMIC) is learning how to read, navigate and when opportune use local practical norms to improve service delivery when possible and to help them operate in these new roles. ORIGINALITY/VALUE: The authors believe that this paper is the first to empirically examine and discuss hybrid clinical healthcare in the LMICs context. The authors make a novel theoretical contribution by describing the important role of practical norms in LMIC healthcare contexts, alongside managerial and professional norms, and ways in which these provide hybrids with considerable agency which has not been previously discussed in the relevant literature.}, keywords = {Hospital Administrators, Hospitals, District, Humans, kenya, Medical Staff, Hospital, Professional Role, Qualitative Research}, issn = {1758-7247}, doi = {10.1108/JHOM-08-2017-0203}, author = {Nzinga, Jacinta and McGivern, Gerry and Mike English} } @article {1396302, title = {Implementation and acceptability of a heart attack quality improvement intervention in India: a mixed methods analysis of the ACS QUIK trial}, journal = {Implement Sci}, volume = {14}, year = {2019}, month = {2019 02 06}, pages = {12}, abstract = {BACKGROUND: The ACS QUIK trial showed that a multicomponent quality improvement toolkit intervention resulted in improvements in processes of care for patients with acute myocardial infarction in Kerala but did not improve clinical outcomes in the context of background improvements in care. We describe the development of the ACS QUIK intervention and evaluate its implementation, acceptability, and sustainability. METHODS: We performed a mixed methods process evaluation alongside a cluster randomized, stepped-wedge trial in Kerala, India. The ACS QUIK intervention aimed to reduce the rate of major adverse cardiovascular events at 30 days compared with usual care across 63 hospitals (n = 21,374 patients). The ACS QUIK toolkit intervention, consisting of audit and feedback report, admission and discharge checklists, patient education materials, and guidelines for the development of code and rapid response teams, was developed based on formative qualitative research in Kerala and from systematic reviews. After four or more months of the center{\textquoteright}s participation in the toolkit intervention phase of the trial, an online survey and physician interviews were administered. Physician interviews focused on evaluating the implementation and acceptability of the toolkit intervention. A framework analysis of transcripts incorporated context and intervening mechanisms. RESULTS: Among 63 participating hospitals, 22 physicians (35\%) completed online surveys. Of these, 17 (77\%) respondents reported that their hospital had a cardiovascular quality improvement team, 18 (82\%) respondents reported having read an audit report, admission checklist, or discharge checklist, and 19 (86\%) respondents reported using patient education materials. Among the 28 interviewees (44\%), facilitators of toolkit intervention implementation were physicians{\textquoteright} support and leadership, hospital administrators{\textquoteright} support, ease-of-use of checklists and patient education materials, and availability of training opportunities for staff. Barriers that influenced the implementation or acceptability of the toolkit intervention for physicians included time and staff constraints, Internet access, patient volume, and inadequate understanding of the quality improvement toolkit intervention. CONCLUSIONS: Implementation and acceptability of the ACS QUIK toolkit intervention were enhanced by hospital-level management support, physician and team support, and usefulness of checklists and patient education materials. Wider and longer-term use of the toolkit intervention and its expansion to potentially other cardiovascular conditions or other locations where the quality of care is not as high as in the ACS QUIK trial may be useful for improving acute cardiovascular care in Kerala and beyond. TRIAL REGISTRATION: NCT02256657.}, keywords = {Cluster Analysis, Feedback, Female, Humans, Implementation Science, India, Male, Middle Aged, Myocardial Infarction, Patient Admission, Patient Discharge, Patient Education as Topic, Practice Guidelines as Topic, Qualitative Research, Quality Improvement}, issn = {1748-5908}, doi = {10.1186/s13012-019-0857-7}, author = {Singh, Kavita and Devarajan, Raji and Mohanan, Padinhare P and Baldridge, Abigail S and Kondal, Dimple and Victorson, David E and Karmali, Kunal N and Zhao, Lihui and Lloyd-Jones, Donald M and Prabhakaran, Dorairaj and Goenka, Shifalika and Huffman, Mark D and ACS QUIK Investigators} } @article {1396325, title = {Latent class analysis of the social determinants of health-seeking behaviour for delivery among pregnant women in Malawi}, journal = {BMJ Glob Health}, volume = {4}, year = {2019}, month = {2019}, pages = {e000930}, abstract = {Introduction: In the era of Sustainable Development Goals, reducing maternal and neonatal mortality is a priority. With one of the highest maternal mortality ratios in the world, Malawi has a significant opportunity for improvement. One effort to improve maternal outcomes involves increasing access to high-quality health facilities for delivery. This study aimed to determine the role that quality plays in women{\textquoteright}s choice of delivery facility. Methods: A revealed-preference latent class analysis was performed with data from 6625 facility births among women in Malawi from 2013 to 2014. Responses were weighted for national representativeness, and model structure and class number were selected using the Bayesian information criterion. Results: Two classes of preferences exist for pregnant women in Malawi. Most of the population 65.85\% (95\% CI 65.847\% to 65.853\%) prefer closer facilities that do not charge fees. The remaining third (34.15\%, 95\% CI 34.147\% to 34.153\%) prefers central hospitals, facilities with higher basic obstetric readiness scores and locations further from home. Women in this class are more likely to be older, literate, educated and wealthier than the majority of women. Conclusion: For only one-third of pregnant Malawian women, structural quality of care, as measured by basic obstetric readiness score, factored into their choice of facility for delivery. Most women instead prioritise closer care and care without fees. Interventions designed to increase access to high-quality care in Malawi will need to take education, distance, fees and facility type into account, as structural quality alone is not predictive of facility type selection in this population.}, issn = {2059-7908}, doi = {10.1136/bmjgh-2018-000930}, author = {Yorlets, Rachel R and Iverson, Katherine R and Leslie, Hannah H and Gage, Anna Davies and Sanam Roder-DeWan and Nsona, Humphreys and Shrime, Mark G} } @article {1396326, title = {Measuring quality of care for all women and newborns: how do we know if we are doing it right? A review of facility assessment tools}, journal = {Lancet Glob Health}, volume = {7}, year = {2019}, month = {2019 05}, pages = {e624-e632}, abstract = {BACKGROUND: Ensuring quality of care during pregnancy and childbirth is crucial to improving health outcomes and reducing preventable mortality and morbidity among women and their newborns. In this pursuit, WHO developed a framework and standards, defining 31 quality statements and 352 quality measures to assess and improve quality of maternal and newborn care in health-care facilities. We aimed to assess the capacity of globally used, large-scale facility assessment tools to measure quality of maternal and newborn care as per the WHO framework. METHODS: We identified assessment tools through a purposive sample that met the following inclusion criteria: multicountry, facility-level, major focus on maternal and newborn health, data on input and process indicators, used between 2007 and 2017, and currently in use. We matched questions in the tools with 274 quality measures associated with inputs and processes within the WHO standards. We excluded quality measures relating to outcomes because these are not routinely measured by many assessment tools. We used descriptive statistics to calculate how many quality measures could be assessed using each of the tools under review. Each tool was assigned a 1 for fulfilling a quality measure based on the presence of any or all components as indicated in the standards. FINDINGS: Five surveys met our inclusion criteria: the Service Provision Assessment (SPA), developed for the Demographic and Health Surveys programme; the Service Availability and Readiness Assessment, developed by WHO; the Needs Assessment of Emergency Obstetric and Newborn Care developed by the Averting Maternal Death and Disability programme at Columbia University; and the World Bank{\textquoteright}s Service Delivery Indicator (SDI) and Impact Evaluation Toolkit for Results Based Financing in Health. The proportion of quality measures covered ranged from 62\% for the SPA to 12\% for the SDI. Although the broadest tool addressed parts of each of the 31 quality statements, 68 (25\%) of 274 input and process quality measures were not measured at all. Measures of health information systems and patient experience of care were least likely to be included. INTERPRETATION: Existing facility assessment tools provide a valuable way to assess quality of maternal and newborn care as one element within the national measurement toolkit. Guidance is clearly needed on priority measures and for better harmonisation across tools to reduce measurement burden and increase data use for quality improvement. Targeted development of measurement modules to address important gaps is a key priority for research. FUNDING: None.}, keywords = {Female, Humans, Infant, Newborn, Maternal Health Services, Maternal-Child Health Centers, Quality Assurance, Health Care, Quality Indicators, Health Care, Quality of Health Care, World Health Organization}, issn = {2214-109X}, doi = {10.1016/S2214-109X(19)30033-6}, author = {Brizuela, Vanessa and Leslie, Hannah H and Sharma, Jigyasa and Langer, Ana and Tun{\c c}alp, {\"O}zge} } @article {1396327, title = {National Commissions on High Quality Health Systems: activities, challenges, and future directions}, journal = {Lancet Glob Health}, volume = {7}, year = {2019}, month = {2019 02}, pages = {e179-e180}, keywords = {Advisory Committees, Argentina, Delivery of Health Care, Ethiopia, Humans, Malawi, mexico, Nepal, Philippines, Quality Assurance, Health Care, Quality of Health Care, Senegal, South Africa, Tanzania}, issn = {2214-109X}, doi = {10.1016/S2214-109X(18)30528-X} } @article {1396293, title = {Personalized public health: An implementation research agenda for the HIV response and beyond}, journal = {PLoS Med}, volume = {16}, year = {2019}, month = {2019 12}, pages = {e1003020}, keywords = {HIV Infections, Humans, Precision Medicine, Public Health}, issn = {1549-1676}, doi = {10.1371/journal.pmed.1003020}, author = {Geng, Elvin H and Holmes, Charles B and Moshabela, Mosa and Sikazwe, Izukanji and Petersen, Maya L} } @article {1396308, title = {PHC Progression Model: a novel mixed-methods tool for measuring primary health care system capacity}, journal = {BMJ Glob Health}, volume = {4}, year = {2019}, month = {2019}, pages = {e001822}, abstract = {High-performing primary health care (PHC) is essential for achieving universal health coverage. However, in many countries, PHC is weak and unable to deliver on its potential. Improvement is often limited by a lack of actionable data to inform policies and set priorities. To address this gap, the Primary Health Care Performance Initiative (PHCPI) was formed to strengthen measurement of PHC in low-income and middle-income countries in order to accelerate improvement. PHCPI{\textquoteright}s Vital Signs Profile was designed to provide a comprehensive snapshot of the performance of a country{\textquoteright}s PHC system, yet quantitative information about PHC systems{\textquoteright} capacity to deliver high-quality, effective care was limited by the scarcity of existing data sources and metrics. To systematically measure the capacity of PHC systems, PHCPI developed the PHC Progression Model, a rubric-based mixed-methods assessment tool. The PHC Progression Model is completed through a participatory process by in-country teams and subsequently reviewed by PHCPI to validate results and ensure consistency across countries. In 2018, PHCPI partnered with five countries to pilot the tool and found that it was feasible to implement with fidelity, produced valid results, and was highly acceptable and useful to stakeholders. Pilot results showed that both the participatory assessment process and resulting findings yielded novel and actionable insights into PHC strengths and weaknesses. Based on these positive early results, PHCPI will support expansion of the PHC Progression Model to additional countries to systematically and comprehensively measure PHC system capacity in order to identify and prioritise targeted improvement efforts.}, issn = {2059-7908}, doi = {10.1136/bmjgh-2019-001822}, author = {Ratcliffe, Hannah L and Schwarz, Dan and Lisa R Hirschhorn and Cejas, Cintia and Diallo, Abdoulaye and Elorrio, Ezequiel Garcia and Fifield, Jocelyn and Gashumba, Diane and Hartshorn, Lucy and Leydon, Nicholas and Mohamed, Mohamed and Nakamura, Yoriko and Youssoupha Ndiaye and Novignon, Jacob and Ofosu, Anthony and Sanam Roder-DeWan and Rwiyereka, Angelique and Secci, Federica and Veillard, Jeremy H and Bitton, Asaf} } @article {1396288, title = {Quality of care for children with severe disease in the Democratic Republic of the Congo}, journal = {BMC Public Health}, volume = {19}, year = {2019}, month = {2019 Dec 02}, pages = {1608}, abstract = {BACKGROUND: Despite the almost universal adoption of Integrated Management of Childhood Illness (IMCI) guidelines for the diagnosis and treatment of sick children under the age of five in low- and middle-income countries, child mortality remains high in many settings. One possible explanation of the continued high mortality burden is lack of compliance with diagnostic and treatment protocols. We test this hypothesis in a sample of children with severe illness in the\ Democratic\ Republic of\ the\ Congo (DRC). METHODS: One thousand one hundred eighty under-five clinical visits were observed across a regionally representative sample of 321 facilities in the\ DRC. Based on a detailed list of disease symptoms observed, patients with severe febrile disease (including malaria), severe pneumonia, and severe dehydration were identified. For all three disease categories, treatments were then compared to recommended case management following IMCI guidelines. RESULTS: Out of 1180 under-five consultations observed, 332 patients (28\%) had signs of severe febrile disease, 189 patients (16\%) had signs of severe pneumonia, and 19 patients (2\%) had signs of severe dehydration. Overall, providers gave the IMCI-recommended treatment in 42\% of cases of these three severe diseases. Less than 15\% of children with severe disease were recommended to receive in-patient care either in the facility they visited or in a higher-level facility. CONCLUSIONS: These results suggest that adherence to IMCI protocols for severe disease remains remarkably low in the DRC. There is a critical need to identify and implement effective approaches for improving the quality of care for severely ill children in settings with high child mortality.}, keywords = {Case Management, Child, Preschool, Clinical Protocols, Dehydration, Democratic Republic of the Congo, Female, Fever, Humans, Infant, Infant, Newborn, Male, Pneumonia, Quality of Health Care, Referral and Consultation}, issn = {1471-2458}, doi = {10.1186/s12889-019-7853-3}, author = {Clarke-Deelder, Emma and Shapira, Gil and Samaha, Hadia and Fritsche, Gy{\"o}rgy B{\`e}la and Fink, G{\"u}nther} } @article {1396303, title = {Rationale and protocol for estimating the economic value of a multicomponent quality improvement strategy for diabetes care in South Asia}, journal = {Glob Health Res Policy}, volume = {4}, year = {2019}, month = {2019}, pages = {7}, abstract = {Background: Economic dimensions of implementing quality improvement for diabetes care are understudied worldwide. We describe the economic evaluation protocol within a randomised controlled trial that tested a multi-component quality improvement (QI) strategy for individuals with poorly-controlled type 2 diabetes in South Asia. Methods/design: This economic evaluation of the Centre for Cardiometabolic Risk Reduction in South Asia (CARRS) randomised trial involved 1146 people with poorly-controlled type 2 diabetes receiving care at 10 diverse diabetes clinics across India and Pakistan. The economic evaluation comprises both a within-trial cost-effectiveness analysis (mean 2.5 years follow up) and a microsimulation model-based cost-utility analysis (life-time horizon). Effectiveness measures include multiple risk factor control (achieving HbA1c \< 7\% and blood pressure \< 130/80 mmHg and/or LDL-cholesterol\< 100 mg/dl), and patient reported outcomes including quality adjusted life years (QALYs) measured by EQ-5D-3 L, hospitalizations, and diabetes related complications at the trial end. Cost measures include direct medical and non-medical costs relevant to outpatient care (consultation fee, medicines, laboratory tests, supplies, food, and escort/accompanying person costs, transport) and inpatient care (hospitalization, transport, and accompanying person costs) of the intervention compared to usual diabetes care. Patient, healthcare system, and societal perspectives will be applied for costing. Both cost and health effects will be discounted at 3\% per year for within trial cost-effectiveness analysis over 2.5 years and decision modelling analysis over a lifetime horizon. Outcomes will be reported as the incremental cost-effectiveness ratios (ICER) to achieve multiple risk factor control, avoid diabetes-related complications, or QALYs gained against varying levels of willingness to pay threshold values. Sensitivity analyses will be performed to assess uncertainties around ICER estimates by varying costs (95\% CIs) across public vs. private settings and using conservative estimates of effect size (95\% CIs) for multiple risk factor control. Costs will be reported in US$ 2018. Discussion: We hypothesize that the additional upfront costs of delivering the intervention will be counterbalanced by improvements in clinical outcomes and patient-reported outcomes, thereby rendering this multi-component QI intervention cost-effective in resource constrained South Asian settings. Trial registration: ClinicalTrials.gov: NCT01212328.}, issn = {2397-0642}, doi = {10.1186/s41256-019-0099-x}, author = {Singh, Kavita and Ali, Mohammed K and Devarajan, Raji and Shivashankar, Roopa and Kondal, Dimple and Ajay, Vamadevan S and Menon, V Usha and Varthakavi, Premlata K and Viswanathan, Vijay and Dharmalingam, Mala and Bantwal, Ganapati and Sahay, Rakesh Kumar and Masood, Muhammad Qamar and Khadgawat, Rajesh and Desai, Ankush and Prabhakaran, Dorairaj and Narayan, K M Venkat and Phillips, Victoria L and Tandon, Nikhil and CARRS Trial Group} } @article {1396315, title = {Strengthening Mentoring in Low- and Middle-Income Countries to Advance Global Health Research: An Overview}, journal = {Am J Trop Med Hyg}, volume = {100}, year = {2019}, month = {2019 01}, pages = {3-8}, abstract = {Mentoring is a proven path to scientific progress, but it is not a common practice in low- and middle-income countries (LMICs). Existing mentoring approaches and guidelines are geared toward high-income country settings, without considering in detail the differences in resources, culture, and structure of research systems of LMICs. To address this gap, we conducted five Mentoring-the-Mentor workshops in Africa, South America, and Asia, which aimed at strengthening the capacity for evidence-based, LMIC-specific institutional mentoring programs globally. The outcomes of the workshops and two follow-up working meetings are presented in this special edition of the . Seven articles offer recommendations on how to tailor mentoring to the context and culture of LMICs, and provide guidance on how to implement mentoring programs. This introductory article provides both a prelude and executive summary to the seven articles, describing the motivation, cultural context and relevant background, and presenting key findings, conclusions, and recommendations.}, keywords = {Africa, Asia, Biomedical Research, Cross-Cultural Comparison, Developing Countries, education, Global Health, Humans, Income, Institutionalization, Mentoring, Mentors, South America, Teaching}, issn = {1476-1645}, doi = {10.4269/ajtmh.18-0556}, author = {Lescano, Andres G and Cohen, Craig R and Raj, Tony and Rispel, Laetitia and Garcia, Patricia J and Zunt, Joseph R and Hamer, Davidson H and Heimburger, Douglas C and Chi, Benjamin H and Ko, Albert I and Bukusi, Elizabeth A} } @article {1394568, title = {High-quality health systems in the Sustainable Development Goals era: time for a revolution}, journal = {The Lancet Global Health}, year = {2018}, url = {https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(18)30386-3/fulltext}, author = {Margaret E Kruk and Anna Gage and Catherine Arsenault, et al.} } @article {1394570, title = {Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries}, journal = {The Lancet}, year = {2018}, url = {https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31668-4/fulltext}, author = {Margaret E Kruk and Anna Gage and Naima T Joseph and Goodarz Danaei and Sebasti{\'a}n Garc{\'\i}a-Sais{\'o} and Joshua A Salomon} } @article {1394573, title = {Three global health-care quality reports in 2018}, journal = {The Lancet}, year = {2018}, url = {https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31430-2/fulltext}, author = {Donald M Berwick and Edward Kelley and Margaret E Kruk and Sania Nishtar and Muhammad Ali Pate} } @article {1396318, title = {Advancing Women Leaders in Global Health: Getting to Solutions}, journal = {Ann Glob Health}, volume = {84}, year = {2018}, month = {2018 11 05}, pages = {743-752}, abstract = {BACKGROUND: Women comprise 75\% of the health workforce in many countries and the majority of students in academic global health tracks but are underrepresented in global health leadership. This study aimed to elucidate prevailing attitudes, perceptions, and beliefs of women and men regarding opportunities and barriers for women{\textquoteright}s career advancement, as well as what can be done to address barriers going forward. METHODS: This was a convergent mixed-methods, cross-sectional, anonymous, online study of participants, applicants, and those who expressed an interest in the Women Leaders in Global Health Conference at Stanford University October 11-12, 2017. Respondents completed a 26-question survey regarding beliefs about barriers and solutions to addressing advancement for women in global health. FINDINGS: 405 participants responded: 96.7\% were female, 61.6\% were aged 40 or under, 64.0\% were originally from high-income countries. Regardless of age or country of origin, leading barriers were: lack of mentorship, challenges of balancing work and home, gender bias, and lack of assertiveness/confidence. Proposed solutions were categorized as individual or meta-level solutions and included senior women seeking junior women for mentorship and sponsorship, junior women pro-actively making their desire for leadership known, and institutions incentivizing mentorship and implementing targeted recruitment to improve diversity of leadership. INTERPRETATION: This study is the first of its kind to attempt to quantify both the barriers to advancement for women leaders in global health as well as the potential solutions. While there is no shortage of barriers, we believe there is room for optimism. A new leadership paradigm that values diversity of thought and diversity of experience will benefit not only the marginalized groups that need to gain representation at the table, but ultimately the broader population who may benefit from new ways of approaching long-standing, intractable problems.}, keywords = {Adult, Aged, Career Choice, Cross-Sectional Studies, Faculty, Medical, Female, Global Health, Humans, Leadership, Male, Mentors, Middle Aged, Physicians, Women, Retrospective Studies, Sexism}, issn = {2214-9996}, doi = {10.29024/aogh.2384}, author = {Moyer, Cheryl A and Abedini, Nauzley C and Youngblood, Jessica and Talib, Zohray and Jayaraman, Tanvi and Manzoor, Mehr and Larson, Heidi J and Garcia, Patricia J and Binagwaho, Agnes and Burke, Katherine S and Barry, Michele} } @article {1396257, title = {Are we ready for a quality revolution?}, journal = {Lancet Glob Health}, volume = {6}, year = {2018}, month = {2018 02}, pages = {e121}, keywords = {Delivery of Health Care, Global Health, Humans, Quality of Health Care}, issn = {2214-109X}, doi = {10.1016/S2214-109X(17)30500-4}, author = {Margaret E. Kruk} } @article {1396328, title = {Barriers and opportunities to improve the foundations for high-quality healthcare in the Mexican Health System}, journal = {Health Policy Plan}, volume = {33}, year = {2018}, month = {2018 Dec 01}, pages = {1073-1082}, abstract = {This study aimed to describe the foundations for quality of care (QoC) in the Mexican public health sector and identify barriers to quality evaluation and improvement from the perspective of the QoC leaders of the main public health sector institutions: Ministry of Health (MoH), the Mexican Institute of Social Security (IMSS) and the Institute of Social Security of State Workers (ISSSTE). We administered a semi-structured online questionnaire that gathered information on foundations (governance, health workforce, platforms, tools and population), evaluation and improvement activities for QoC; 320 leaders from MoH, IMSS and ISSSTE participated. We used thematic content and descriptive analyses to analyse the data. We found that QoC foundations, evaluation and improvement activities pose essential challenges for the Mexican health sector. Governance for QoC is weakly aligned across MoH, IMSS and ISSSTE. Each institution follows its own agenda of evaluation and improvement programmes and has distinct QoC indicators and information systems. The institutions share similar barriers to strengthening QoC: poor organizational structure at a facility level, scarcity of financial resources, lack of training in QoC for executive/managerial staff and health professionals and limited public participation. In conclusion, a stronger legal framework and policy dialogue is needed to foster governance by the MoH, to define and align health sector-wide QoC policies, and to set common goals and articulate QoC improvement actions among institutions. Robust QoC organizational structure with designated staff and clarity on their responsibilities should be established at all levels of healthcare. Investment is necessary to fund formal and in-service QoC training programmes for health professionals and to reinforce quality evaluation and improvement activities and quality information systems. QoC evaluation results should be available to healthcare providers and the population. Active public participation in the design and implementation of improvement initiatives should be strengthened.}, keywords = {Delivery of Health Care, Health Services Research, Health Workforce, Humans, mexico, public sector, Quality Improvement, Quality of Health Care, Surveys and Questionnaires}, issn = {1460-2237}, doi = {10.1093/heapol/czy098}, author = {Doubova, Svetlana V and Sebasti{\'a}n Garc{\'\i}a-Sais{\'o} and P{\'e}rez-Cuevas, Ricardo and Sarabia-Gonz{\'a}lez, Odet and Pacheco-Estrello, Paulina and Leslie, Hannah H and Santamar{\'\i}a, Carmen and Torres-Arreola, Laura Del Pilar and Infante-Casta{\~n}eda, Claudia} } @article {1396253, title = {Can India{\textquoteright}s primary care facilities deliver? A cross-sectional assessment of the Indian public health system{\textquoteright}s capacity for basic delivery and newborn services}, journal = {BMJ Open}, volume = {8}, year = {2018}, month = {2018 06 04}, pages = {e020532}, abstract = {OBJECTIVES: To assess input and process capacity for basic delivery and newborn (intrapartum care hereafter) care in the Indian public health system and to describe differences in facility capacity between rural and urban areas and across states. DESIGN: Cross-sectional study. SETTING: Data from the nationally representative 2012-2014 District Level Household and Facility Survey, which includes a census of community health centres (CHC) and sample of primary health centres (PHC) across 30 states and union territories in India. PARTICIPANTS: 8536 PHCs and 4810 CHCs. OUTCOME MEASURES: We developed a summative index of 33 structural and process capacity items matching the Indian Public Health Standards for PHCs as a metric of minimum facility capacity for intrapartum care. We assessed differences in performance on this index across facility type and location. RESULTS: About 30\% of PHCs and 5\% of CHCs reported not offering any intrapartum care. Among those offering services, volumes were low: median monthly delivery volume was 8 (IQR=13) in PHCs and 41 (IQR=73) in CHCs. Both PHCs and CHCs failed to meet the national standards for basic intrapartum care capacity. Mean facility capacity was low in PHCs in both urban (0.64) and rural (0.63) areas, while in CHCs, capacity was slightly higher in urban areas (0.77vs0.74). Gaps were most striking in availability of skilled human resources and emergency obstetric services. Poor capacity facilities were more concentrated in the more impoverished states, with 37\% of districts from these states receiving scores in the lowest third of the facility capacity index (\<0.70), compared with 21\% of districts otherwise. CONCLUSIONS: Basic intrapartum care capacity in Indian public primary care facilities is weak in both rural and urban areas, especially lacking in the poorest states with worst health outcomes. Improving maternal and newborn health outcomes will require focused attention to quality measurement, accountability mechanisms and quality improvement. Policies to address deficits in skilled providers and emergency service availability are urgently required.}, keywords = {Censuses, Community Health Centers, Cross-Sectional Studies, Emergency Medical Services, Female, Health Services Accessibility, Humans, India, Infant, Newborn, Maternal Health Services, Population, Pregnancy, Primary Health Care, Public Health}, issn = {2044-6055}, doi = {10.1136/bmjopen-2017-020532}, author = {Sharma, Jigyasa and Leslie, Hannah H and Regan, Mathilda and Nambiar, Devaki and Margaret E Kruk} } @article {1396255, title = {Content of Care in 15,000 Sick Child Consultations in Nine Lower-Income Countries}, journal = {Health Serv Res}, volume = {53}, year = {2018}, month = {2018 08}, pages = {2084-2098}, abstract = {OBJECTIVE: Describe content of clinical care for sick children in low-resource settings. DATA SOURCES: Nationally representative health facility surveys in Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Tanzania, and Uganda from 2007 to 2015. STUDY DESIGN: Clinical visits by sick children under 5 years were observed and caregivers interviewed. We describe duration and content of the care in the visit and estimate associations between increased content and caregiver knowledge and satisfaction. PRINCIPAL FINDINGS: The median duration of 15,444 observations was 8\ minutes; providers performed 8.4 of a maximum 24 clinical actions per visit. Content of care was minimally greater for severely ill children. Each additional clinical action was associated with 2 percent higher caregiver knowledge. CONCLUSIONS: Consultations for children in nine lower-income countries are brief and limited. A greater number of clinical actions was associated with caregiver knowledge and satisfaction.}, keywords = {Africa, Caregivers, Child Health Services, Child Mortality, Child, Preschool, Female, Haiti, Health Facilities, Health Knowledge, Attitudes, Practice, Humans, Infant, Infant, Newborn, Interviews as Topic, Male, Nepal, Poverty, Quality of Health Care, Referral and Consultation}, issn = {1475-6773}, doi = {10.1111/1475-6773.12842}, author = {Margaret E Kruk and Gage, Anna D and Mbaruku, Godfrey M and Leslie, Hannah H} } @article {1396254, title = {Distribution and determinants of pneumonia diagnosis using Integrated Management of Childhood Illness guidelines: a nationally representative study in Malawi}, journal = {BMJ Glob Health}, volume = {3}, year = {2018}, month = {2018}, pages = {e000506}, abstract = {Background: Pneumonia remains the leading cause of child mortality in sub-Saharan Africa. The Integrated Management of Childhood Illness (IMCI) strategy was developed to standardise care in low-income and middle-income countries for major childhood illnesses and can effectively improve healthcare worker performance. Suboptimal clinical evaluation can result in missed diagnoses and excess morbidity and mortality. We estimate the sensitivity of pneumonia diagnosis and investigate its determinants among children in Malawi. Methods: Data were obtained from the 2013-2014 Service Provision Assessment survey, a census of health facilities in Malawi that included direct observation of care and re-examination of children by trained observers. We calculated sensitivity of pneumonia diagnosis and used multilevel log-binomial regression to assess factors associated with diagnostic sensitivity. Results: 3136 clinical visits for children 2-59 months old were observed at 742 health facilities. Healthcare workers completed an average of 30\% (SD 13\%) of IMCI guidelines in each encounter. 573 children met the IMCI criteria for pneumonia; 118 (21\%) were correctly diagnosed. Advanced practice clinicians were more likely than other providers to diagnose pneumonia correctly (adjusted relative risk 2.00, 95\% CI 1.21 to 3.29). Clinical quality was strongly associated with correct diagnosis: sensitivity was 23\% in providers at the 75th percentile for guideline adherence compared with 14\% for those at the 25th percentile. Contextual factors, facility structural readiness, and training or supervision were not associated with sensitivity. Conclusions: Care quality for Malawian children is poor, with low guideline adherence and missed diagnosis for four of five children with pneumonia. Better sensitivity is associated with provider type and higher adherence to IMCI. Existing interventions such as training and supportive supervision are associated with higher guideline adherence, but are insufficient to meaningfully improve sensitivity. Innovative and scalable quality improvement interventions are needed to strengthen health systems and reduce avoidable child mortality.}, issn = {2059-7908}, doi = {10.1136/bmjgh-2017-000506}, author = {Uwemedimo, Omolara T and Lewis, Todd P and Essien, Elsie A and Chan, Grace J and Nsona, Humphreys and Margaret E Kruk and Leslie, Hannah H} } @article {1396252, title = {Does quality influence utilization of primary health care? Evidence from Haiti}, journal = {Global Health}, volume = {14}, year = {2018}, month = {2018 06 20}, pages = {59}, abstract = {BACKGROUND: Expanding coverage of primary healthcare services such as antenatal care and vaccinations is a global health priority; however, many Haitians do not utilize these services. One reason may be that the population avoids low quality health facilities. We examined how facility infrastructure and the quality of primary health care service delivery were associated with community utilization of primary health care services in Haiti. METHODS: We constructed two composite measures of quality for all Haitian facilities using the 2013 Service Provision Assessment survey. We geographically linked population clusters from the Demographic and Health Surveys to nearby facilities offering primary health care services. We assessed the cross-sectional association between quality and utilization of four primary care services: antenatal care, postnatal care, vaccinations and sick child care, as well as one more complex service: facility delivery. RESULTS: Facilities performed poorly on both measures of quality, scoring 0.55 and 0.58 out of 1 on infrastructure and service delivery quality respectively. In rural areas, utilization of several primary cares services (antenatal care, postnatal care, and vaccination) was associated with both infrastructure and quality of service delivery, with stronger associations for service delivery. Facility delivery was associated with infrastructure quality, and there was no association for sick child care. In urban areas, care utilization was not associated with either quality measure. CONCLUSIONS: Poor quality of care may deter utilization of beneficial primary health care services in rural areas of Haiti. Improving health service quality may offer an opportunity not only to improve health outcomes for patients, but also to expand coverage of key primary health care services.}, keywords = {Cross-Sectional Studies, Haiti, Humans, Primary Health Care, Quality of Health Care, Rural Population}, issn = {1744-8603}, doi = {10.1186/s12992-018-0379-0}, author = {Gage, Anna D and Leslie, Hannah H and Bitton, Asaf and Jerome, J Gregory and Joseph, Jean Paul and Thermidor, Roody and Margaret E Kruk} } @article {1396304, title = {Effect of a Quality Improvement Intervention on Clinical Outcomes in Patients in India With Acute Myocardial Infarction: The ACS QUIK Randomized Clinical Trial}, journal = {JAMA}, volume = {319}, year = {2018}, month = {2018 02 13}, pages = {567-578}, abstract = {Importance: Wide heterogeneity exists in acute myocardial infarction treatment and outcomes in India. Objective: To evaluate the effect of a locally adapted quality improvement tool kit on clinical outcomes and process measures in Kerala, a southern Indian state. Design, Setting, and Participants: Cluster randomized, stepped-wedge clinical trial conducted between November 10, 2014, and November 9, 2016, in 63 hospitals in Kerala, India, with a last date of follow-up of December 31, 2016. During 5 predefined steps over the study period, hospitals were randomly selected to move in a 1-way crossover from the control group to the intervention group. Consecutively presenting patients with acute myocardial infarction were offered participation. Interventions: Hospitals provided either usual care (control group; n = 10 066 participants [step 0: n = 2915; step 1: n = 2649; step 2: n = 2251; step 3: n = 1422; step 4; n = 829; step 5: n = 0]) or care using a quality improvement tool kit (intervention group; n = 11 308 participants [step 0: n = 0; step 1: n = 662; step 2: n = 1265; step 3: n = 2432; step 4: n = 3214; step 5: n = 3735]) that consisted of audit and feedback, checklists, patient education materials, and linkage to emergency cardiovascular care and quality improvement training. Main Outcomes and Measures: The primary outcome was the composite of all-cause death, reinfarction, stroke, or major bleeding using standardized definitions at 30 days. Secondary outcomes included the primary outcome{\textquoteright}s individual components, 30-day cardiovascular death, medication use, and tobacco cessation counseling. Mixed-effects logistic regression models were used to account for clustering and temporal trends. Results: Among 21 374 eligible randomized participants (mean age, 60.6 [SD, 12.0] years; n = 16 183 men [76\%] ; n = 13 689 [64\%] with ST-segment elevation myocardial infarction), 21 079 (99\%) completed the trial. The primary composite outcome was observed in 5.3\% of the intervention participants and 6.4\% of the control participants. The observed difference in 30-day major adverse cardiovascular event rates between the groups was not statistically significant after adjustment (adjusted risk difference, -0.09\% [95\% CI, -1.32\% to 1.14\%]; adjusted odds ratio, 0.98 [95\% CI, 0.80-1.21]). The intervention group had a higher rate of medication use including reperfusion but no effect on tobacco cessation counseling. There were no unexpected adverse events reported. Conclusions and Relevance: Among patients with acute myocardial infarction in Kerala, India, use of a quality improvement intervention compared with usual care did not decrease a composite of 30-day major adverse cardiovascular events. Further research is needed to understand the lack of efficacy. Trial Registration: clinicaltrials.gov Identifier: NCT02256657.}, keywords = {Aged, Female, Humans, India, Intention to Treat Analysis, Logistic Models, Male, Middle Aged, Myocardial Infarction, Practice Guidelines as Topic, Quality Improvement, Research Design, Treatment Outcome}, issn = {1538-3598}, doi = {10.1001/jama.2017.21906}, author = {Huffman, Mark D and Mohanan, Padinhare P and Devarajan, Raji and Baldridge, Abigail S and Kondal, Dimple and Zhao, Lihui and Ali, Mumtaj and Krishnan, Mangalath N and Natesan, Syam and Gopinath, Rajesh and Viswanathan, Sunitha and Stigi, Joseph and Joseph, Johny and Chozhakkat, Somanathan and Lloyd-Jones, Donald M and Prabhakaran, Dorairaj and Acute Coronary Syndrome Quality Improvement in Kerala (ACS QUIK) Investigators} } @article {1396296, title = {Evaluation of a community-based intervention to improve maternal and neonatal health service coverage in the most rural and remote districts of Zambia}, journal = {PLoS One}, volume = {13}, year = {2018}, month = {2018}, pages = {e0190145}, abstract = {BACKGROUND: A community-based intervention comprising both men and women, known as Safe Motherhood Action Groups (SMAGs), was implemented in four of Zambia{\textquoteright}s poorest and most remote districts to improve coverage of selected maternal and neonatal health interventions. This paper reports on outcomes in the coverage of maternal and neonatal care interventions, including antenatal care (ANC), skilled birth attendance (SBA) and postnatal care (PNC) in the study areas. METHODOLOGY: Three serial cross-sectional surveys were conducted between 2012 and 2015 among 1,652 mothers of children 0-5 months of age using a {\textquoteright}before-and-after{\textquoteright} evaluation design with multi-stage sampling, combining probability proportional to size and simple random sampling. Logistic regression and chi-square test for trend were used to assess effect size and changes in measures of coverage for ANC, SBA and PNC during the intervention. RESULTS: Mothers{\textquoteright} mean age and educational status were non-differentially comparable at all the three-time points. The odds of attending ANC at least four times (aOR 1.63; 95\% CI 1.38-1.99) and SBA (aOR 1.72; 95\% CI 1.38-1.99) were at least 60\% higher at endline than baseline surveillance. A two-fold and four-fold increase in the odds of mothers receiving PNC from an appropriate skilled provider (aOR 2.13; 95\% CI 1.62-2.79) and a SMAG (aOR 4.87; 95\% CI 3.14-7.54), respectively, were observed at endline. Receiving birth preparedness messages from a SMAG during pregnancy (aOR 1.76; 95\% CI, 1.20-2.19) and receiving ANC from a skilled provider (aOR 4.01; 95\% CI, 2.88-5.75) were significant predictors for SBA at delivery and PNC. CONCLUSIONS: Strengthening community-based action groups in poor and remote districts through the support of mothers by SMAGs was associated with increased coverage of maternal and newborn health interventions, measured through ANC, SBA and PNC. In remote and marginalised settings, where the need is greatest, context-specific and innovative task-sharing strategies using community health volunteers can be effective in improving coverage of maternal and neonatal services and hold promise for better maternal and child survival in poorly-resourced parts of sub-Saharan Africa.}, keywords = {Child Health Services, Female, Humans, Infant, Newborn, Maternal Health Services, Pregnancy, Rural Population, Young Adult, Zambia}, issn = {1932-6203}, doi = {10.1371/journal.pone.0190145}, author = {Jacobs, Choolwe and Michelo, Charles and Chola, Mumbi and Oliphant, Nicholas and Halwiindi, Hikabasa and Maswenyeho, Sitali and Baboo, Kumar Sridutt and Moshabela, Mosa} } @article {1396294, title = {HIV Treatment Substantially Decreases Hospitalization Rates: Evidence From Rural South Africa}, journal = {Health Aff (Millwood)}, volume = {37}, year = {2018}, month = {2018 06}, pages = {997-1004}, abstract = {The effect of HIV treatment on hospitalization rates for HIV-infected people has never been established. We quantified this effect in a rural South African community for the period 2009-13. We linked clinical data on HIV treatment start dates for more than 2,000 patients receiving care in the public-sector treatment program with five years of longitudinal data on self-reported hospitalizations from a community-based population cohort of more than 100,000 adults. Hospitalization rates peaked during the first year of treatment and were about five times higher, compared to hospitalization rates after four years on treatment. Earlier treatment initiation could save more than US$300,000 per 1,000 patients over the first four years of HIV treatment, freeing up scarce resources. Future studies on the cost-effectiveness of HIV treatment should include these effects.}, keywords = {Adult, Anti-HIV Agents, Cohort Studies, Databases, Factual, Developing Countries, Female, Health Care Costs, HIV Infections, Hospitalization, Humans, Incidence, Male, Poisson Distribution, Retrospective Studies, Rural Population, South Africa, Young Adult}, issn = {1544-5208}, doi = {10.1377/hlthaff.2017.0820}, author = {Hontelez, Jan A C and Bor, Jacob and Tanser, Frank C and Pillay, Deenan and Moshabela, Mosa and B{\"a}rnighausen, Till} } @article {1396298, title = {Implementation of a community-based intervention in the most rural and remote districts of Zambia: a process evaluation of safe motherhood action groups}, journal = {Implement Sci}, volume = {13}, year = {2018}, month = {2018 05 31}, pages = {74}, abstract = {BACKGROUND: A community-based intervention known as Safe Motherhood Action Groups (SMAGs) was implemented to increase coverage of maternal and neonatal health (MNH) services among the poorest and most remote populations in Zambia. While the outcome evaluation demonstrated statistically significant improvement in the MNH indicators, targets for key indicators were not achieved, and reasons for this shortfall were not known. This study was aimed at understanding why the targeted key indicators for MNH services were not achieved. METHODS: A process evaluation, in accordance with the Medical Research Council (MRC) framework, was conducted in two selected rural districts of Zambia using qualitative approaches. Focus group discussions were conducted with SMAGs, volunteer community health workers, and mothers and in-depth interviews with healthcare providers. Content analysis was done. RESULTS: We found that SMAGs implemented much of the intervention as was intended, particularly in the area of women{\textquoteright}s education and referral to health facilities for skilled MNH services. The SMAGs went beyond their prescribed roles to assist women with household chores and personal problems and used their own resources to enhance the success of the intervention. Deficiencies in the intervention were reported and included poor ongoing support, inadequate supplies and lack of effective transportation such as bicycles needed for the SMAGs to facilitate their work. Factors external to the intervention, such as inadequacy of health services and skilled healthcare providers in facilities where SMAGs referred mothers and poor geographical access, may have led SMAGs to engage in the unintended role of conducting deliveries, thus compromising the outcome of the intervention. CONCLUSION: We found evidence suggesting that although SMAGs continue to play pivotal roles in contribution towards accelerated coverage of MNH services among hard-to-reach populations, they are unable to meet some of the critical sets of MNH service-targeted indicators. The complexities of the implementation mechanisms coupled with the presence of setting specific socio-cultural and geographical contextual factors could partially explain this failure. This suggests a need for innovating existing implementation strategies so as to help SMAGs and any other community health system champions to effectively respond to MNH needs of most-at-risk women and promote universal health coverage targeting hard-to-reach groups.}, keywords = {Female, Focus Groups, Health Services Accessibility, Humans, Maternal Health Services, Pregnancy, Retrospective Studies, Rural Population, Zambia}, issn = {1748-5908}, doi = {10.1186/s13012-018-0766-1}, author = {Jacobs, Choolwe and Michelo, Charles and Moshabela, Mosa} } @article {1396329, title = {The know-do gap in sick child care in Ethiopia}, journal = {PLoS One}, volume = {13}, year = {2018}, month = {2018}, pages = {e0208898}, abstract = {BACKGROUND: While health care provider knowledge is a commonly used measure for process quality of care, evidence demonstrates that providers don{\textquoteright}t always perform as much as they know. We describe this know-do gap for malaria care for sick children among providers in Ethiopia and examine what may predict this gap. METHODS: We use a 2014 nationally-representative survey of Ethiopian providers that includes clinical knowledge vignettes of malaria care and observations of care provided to children in facilities. We compare knowledge and performance of assessment, treatment and counseling items and overall. We subtract performance scores from knowledge and use regression analysis to examine what facility and provider characteristics predict the gap. 512 providers that completed the malaria vignette and were observed providing care to sick children were included in the analysis. RESULTS: Vignette and observed performance were both low, with providers on average scoring 39\% and 34\% respectively. The know-do gap for assessment was only 1\%, while the gap for treatment and counseling items was 39\%. Doctors had the largest gap between knowledge and performance. Only provider type and availability of key equipment significantly predicted the know-do gap. CONCLUSIONS: While both provider knowledge and performance in sick child care are poor, there is a gap between knowledge and performance particularly with regard to treatment and counseling. Interventions to improve quality of care must address not only deficiencies in provider knowledge, but also the gap between knowledge and action.}, keywords = {Adolescent, Child, Child, Preschool, Cross-Sectional Studies, Delivery of Health Care, Ethiopia, Female, Humans, Infant, Infant, Newborn, Malaria, Male, Quality of Health Care}, issn = {1932-6203}, doi = {10.1371/journal.pone.0208898}, author = {Gage, Anna D and Margaret E Kruk and Girma, Tsinuel and Lemango, Ephrem T} } @article {1396314, title = {Patient-centered primary care and self-rated health in 6 Latin American and Caribbean countries: Analysis of a public opinion cross-sectional survey}, journal = {PLoS Med}, volume = {15}, year = {2018}, month = {2018 10}, pages = {e1002673}, abstract = {BACKGROUND: Despite the substantial attention to primary care (PC), few studies have addressed the relationship between patients{\textquoteright} experience with PC and their health status in low-and middle-income countries. This study aimed to (1) test the association between overall patient-centered PC experience (OPCE) and self-rated health (SRH) and (2) identify specific features of patient-centered PC associated with better SRH (i.e., excellent or very good SRH) in 6 Latin American and Caribbean countries. METHODS AND FINDINGS: We conducted a secondary analysis of a 2013 public opinion cross-sectional survey on perceptions and experiences with healthcare systems in Brazil, Colombia, El Salvador, Jamaica, Mexico, and Panama; the data were nationally representative for urban populations. We analyzed 9 features of patient-centered PC. We calculated OPCE score as the arithmetic mean of the PC features. OPCE score ranged from 0 to 1, where 0 meant that the participant did not have any of the 9 patient-centered PC experiences, while 1 meant that he/she reported having all these experiences. After testing for interaction on the additive scale, we analyzed countries pooled for aim 1, with an interaction term for Mexico, and each country separately for aim 2. We used multiple Poisson regression models double-weighted by survey and inverse probability weights to deal with the survey design and missing data. The study included 6,100 participants. The percentage of participants with excellent or very good SRH ranged from 29.5\% in Mexico to 52.4\% in Jamaica. OPCE was associated with reporting excellent or very good SRH in all countries: adjusting for socio-demographic and health covariates, patients with an OPCE score of 1 in Brazil, Colombia, El Salvador, Jamaica, and Panama were more likely to report excellent or very good SRH than those with a score of 0 (adjusted prevalence ratio [aPR] 1.61, 95\% CI 1.37-1.90, p \< 0.001); in Mexico, this association was even stronger (aPR 4.27, 95\% CI 2.34-7.81, p \< 0.001). The specific features of patient-centered PC associated with better SRH differed by country. The perception that PC providers solve most health problems was associated with excellent or very good SRH in Colombia (aPR 1.38, 95\% CI 1.01-1.91, p = 0.046) and Jamaica (aPR 1.21, 95\% CI 1.02-1.43, p = 0.030). Having a provider who knows relevant medical history was positively associated with better SRH in Mexico (aPR 1.47, 95\% CI 1.03-2.12, p = 0.036) but was negatively associated with better SRH in Brazil (aPR 0.71, 95\% CI 0.56-0.89, p = 0.003). Finally, easy contact with PC facility (Mexico: aPR 1.35, 95\% CI 1.04-1.74, p = 0.023), coordination of care (Mexico: aPR 1.53, 95\% CI 1.19-1.98, p = 0.001), and opportunity to ask questions (Brazil: aPR 1.42, 95\% CI 1.11-1.83, p = 0.006) were each associated with better SRH. The main study limitation consists in the analysis being of cross-sectional data, which does not allow making causal inferences or identifying the direction of the association between the variables. CONCLUSIONS: Overall, a higher OPCE score was associated with better SRH in these 6 Latin American and Caribbean countries; associations between specific characteristics of patient-centered PC and SRH differed by country. The findings underscore the importance of high-quality, patient-centered PC as a path to improved population health.}, keywords = {Adult, Brazil, Colombia, communication, Cross-Sectional Studies, El Salvador, Female, Health Care Surveys, Health Status, Humans, Jamaica, Male, mexico, Middle Aged, Panama, Patient Satisfaction, Perception, Physician-Patient Relations, Primary Health Care, Public Opinion, Quality of Health Care, Young Adult}, issn = {1549-1676}, doi = {10.1371/journal.pmed.1002673}, author = {Frederico Guanais and Doubova, Svetlana V and Leslie, Hannah H and Perez-Cuevas, Ricardo and Ezequiel Garc{\'\i}a-Elorrio and Margaret E Kruk} } @article {1396330, title = {Perioperative mortality rates in low-income and middle-income countries: a systematic review and meta-analysis}, journal = {BMJ Glob Health}, volume = {3}, year = {2018}, month = {2018}, pages = {e000810}, abstract = {Introduction: Commission on Global Surgery proposed the perioperative mortality rate (POMR) as one of the six key indicators of the strength of a country{\textquoteright}s surgical system. Despite its widespread use in high-income settings, few studies have described procedure-specific POMR across low-income and middle-income countries (LMICs). We aimed to estimate POMR across a wide range of surgical procedures in LMICs. We also describe how POMR is defined and reported in the LMIC literature to provide recommendations for future monitoring in resource-constrained settings. Methods: We did a systematic review of studies from LMICs published from 2009 to 2014 reporting POMR for any surgical procedure. We extracted select variables in duplicate from each included study and pooled estimates of POMR by type of procedure using random-effects meta-analysis of proportions and the Freeman-Tukey double arcsine transformation to stabilise variances. Results: We included 985 studies conducted across 83 LMICs, covering 191 types of surgical procedures performed on 1 020 869 patients. Pooled POMR ranged from less than 0.1\% for appendectomy, cholecystectomy and caesarean delivery to 20\%-27\% for typhoid intestinal perforation, intracranial haemorrhage and operative head injury. We found no consistent associations between procedure-specific POMR and Human Development Index (HDI) or income-group apart from emergency peripartum hysterectomy POMR, which appeared higher in low-income countries. Inpatient mortality was the most commonly used definition, though only 46.2\% of studies explicitly defined the time frame during which deaths accrued. Conclusions: Efforts to improve access to surgical care in LMICs should be accompanied by investment in improving the quality and safety of care. To improve the usefulness of POMR as a safety benchmark, standard reporting items should be included with any POMR estimate. Choosing a basket of procedures for which POMR is tracked may offer institutions and countries the standardisation required to meaningfully compare surgical outcomes across contexts and improve population health outcomes.}, issn = {2059-7908}, doi = {10.1136/bmjgh-2018-000810}, author = {Ng-Kamstra, Joshua S and Arya, Sumedha and Greenberg, Sarah L M and Kotagal, Meera and Catherine Arsenault and Ljungman, David and Yorlets, Rachel R and Agarwal, Arnav and Frankfurter, Claudia and Nikouline, Anton and Lai, Francis Yi Xing and Palmqvist, Charlotta L and Fu, Terence and Mahmood, Tahrin and Raju, Sneha and Sharma, Sristi and Marks, Isobel H and Bowder, Alexis and Pi, Lebei and John G Meara and Shrime, Mark G} } @article {1396310, title = {Quality improvement and emerging global health priorities}, journal = {Int J Qual Health Care}, volume = {30}, year = {2018}, month = {2018 Apr 20}, pages = {5-9}, abstract = {Quality improvement approaches can strengthen action on a range of global health priorities. Quality improvement efforts are uniquely placed to reorient care delivery systems towards integrated people-centred health services and strengthen health systems to achieve Universal Health Coverage (UHC). This article makes the case for addressing shortfalls of previous agendas by articulating the critical role of quality improvement in the Sustainable Development Goal era. Quality improvement can stimulate convergence between health security and health systems; address global health security priorities through participatory quality improvement approaches; and improve health outcomes at all levels of the health system. Entry points for action include the linkage with antimicrobial resistance and the contentious issue of the health of migrants. The work required includes focussed attention on the continuum of national quality policy formulation, implementation and learning; alongside strengthening the measurement-improvement linkage. Quality improvement plays a key role in strengthening health systems to achieve UHC.}, keywords = {Conservation of Natural Resources, Delivery of Health Care, Global Health, Health Policy, Health Priorities, Humans, Quality Assurance, Health Care, Quality Improvement, Transients and Migrants, Universal Health Insurance}, issn = {1464-3677}, doi = {10.1093/intqhc/mzy007}, author = {Mensah Abrampah, Nana and Syed, Shamsuzzoha Babar and Lisa R Hirschhorn and Nambiar, Bejoy and Iqbal, Usman and Garcia-Elorrio, Ezequiel and Chattu, Vijay Kumar and Devnani, Mahesh and Edward Kelley} } @article {1396312, title = {Research versus practice in quality improvement? Understanding how we can bridge the gap}, journal = {Int J Qual Health Care}, volume = {30}, year = {2018}, month = {2018 Apr 20}, pages = {24-28}, abstract = {The gap between implementers and researchers of quality improvement (QI) has hampered the degree and speed of change needed to reduce avoidable suffering and harm in health care. Underlying causes of this gap include differences in goals and incentives, preferred methodologies, level and types of evidence prioritized and targeted audiences. The Salzburg Global Seminar on {\textquoteright}Better Health Care: How do we learn about improvement?{\textquoteright} brought together researchers, policy makers, funders, implementers, evaluators from low-, middle- and high-income countries to explore how to increase the impact of QI. In this paper, we describe some of the reasons for this gap and offer suggestions to better bridge the chasm between researchers and implementers. Effectively bridging this gap can increase the generalizability of QI interventions, accelerate the spread of effective approaches while also strengthening the local work of implementers. Increasing the effectiveness of research and work in the field will support the knowledge translation needed to achieve quality Universal Health Coverage and the Sustainable Development Goals.}, keywords = {Conservation of Natural Resources, Delivery of Health Care, Health Services Research, Humans, Motivation, Organizational Objectives, Program Development, Quality Improvement, Translational Medical Research}, issn = {1464-3677}, doi = {10.1093/intqhc/mzy018}, author = {Lisa R Hirschhorn and Ramaswamy, Rohit and Devnani, Mahesh and Wandersman, Abraham and Simpson, Lisa A and Garcia-Elorrio, Ezequiel} } @article {1396309, title = {Unpacking the black box of improvement}, journal = {Int J Qual Health Care}, volume = {30}, year = {2018}, month = {2018 Apr 20}, pages = {15-19}, abstract = {During the Salzburg Global Seminar Session 565-{\textquoteright}Better Health Care: How do we learn about improvement?{\textquoteright}, participants discussed the need to unpack the {\textquoteright}black box{\textquoteright} of improvement. The {\textquoteright}black box{\textquoteright} refers to the fact that when quality improvement interventions are described or evaluated, there is a tendency to assume a simple, linear path between the intervention and the outcomes it yields. It is also assumed that it is enough to evaluate the results without understanding the process of by which the improvement took place. However, quality improvement interventions are complex, nonlinear and evolve in response to local settings. To accurately assess the effectiveness of quality improvement and disseminate the learning, there must be a greater understanding of the complexity of quality improvement work. To remain consistent with the language used in Salzburg, we refer to this as {\textquoteright}unpacking the black box{\textquoteright} of improvement. To illustrate the complexity of improvement, this article introduces four quality improvement case studies. In unpacking the black box, we present and demonstrate how Cynefin framework from complexity theory can be used to categorize and evaluate quality improvement interventions. Many quality improvement projects are implemented in complex contexts, necessitating an approach defined as {\textquoteright}probe-sense-respond{\textquoteright}. In this approach, teams experiment, learn and adapt their changes to their local setting. Quality improvement professionals intuitively use the probe-sense-respond approach in their work but document and evaluate their projects using language for {\textquoteright}simple{\textquoteright} or {\textquoteright}complicated{\textquoteright} contexts, rather than the {\textquoteright}complex{\textquoteright} contexts in which they work. As a result, evaluations tend to ask {\textquoteright}How can we attribute outcomes to the intervention?{\textquoteright}, rather than {\textquoteright}What were the adaptations that took place?{\textquoteright}. By unpacking the black box of improvement, improvers can more accurately document and describe their interventions, allowing evaluators to ask the right questions and more adequately evaluate quality improvement interventions.}, keywords = {Anemia, Checklist, Child, Preschool, Female, Humans, India, Information Dissemination, Mali, Organizational Culture, Patient Discharge, Prenatal Care, Program Evaluation, Quality Assurance, Health Care, Quality Improvement, United Kingdom}, issn = {1464-3677}, doi = {10.1093/intqhc/mzy009}, author = {Ramaswamy, Rohit and Reed, Julie and Livesley, Nigel and Boguslavsky, Victor and Garcia-Elorrio, Ezequiel and Sax, Sylvia and Houleymata, Diarra and Kimble, Leighann and Parry, Gareth} } @article {1396297, title = {Why do rural women in the most remote and poorest areas of Zambia predominantly attend only one antenatal care visit with a skilled provider? A qualitative inquiry}, journal = {BMC Health Serv Res}, volume = {18}, year = {2018}, month = {2018 06 05}, pages = {409}, abstract = {BACKGROUND: While focused antenatal care (ANC) has served as an entry point in the continuum of care for both mothers and children, fewer than a third of pregnant women in the most remote and poorest communities of Zambia achieve the four ANC visits recommended by the World Health Organization. Current evidence suggests that attending ANC provided by a skilled healthcare worker at least once is common and associated with skilled birth attendance. The aim of this study was to explain why one ANC visit with a skilled provider seemed more common than four ANC visits among women in the remote and poorest districts of Zambia. METHODS: A qualitative case study design was conducted in 2012 among 84 participants in the selected remote and poorest districts of Zambia. Focus group discussions were conducted with mothers and community health volunteers, while key informant interviews were conducted with healthcare providers. Thematic analysis was conducted. RESULTS: Most women delayed starting antenatal care visits due to uncertainties about the timing for initiation of ANC and due to waiting for confirmation of the pregnancy by an elderly woman. Attendance of ANC once with a skilled provider was due to the need to assess their health status and that of their baby. In some facilities, attendance of ANC at least once was enforced by financial charges imposed on women for late ANC initiation, and/or incentives provided by nongovernmental organisations. Unavailability of services at health posts closest to these remote communities led to failure to return for subsequent ANC visits. Women{\textquoteright}s livelihoods such as nomadic lifestyles made it harder for them to initiate and make additional ANC visits. CONCLUSION: The popularity of ANC attendance once by a skilled provider among the remote and poorest women of Zambia was explained through perceived unavoidable social and economic barriers to care, and the punitive and incentive procedures implemented by health services. Maximising comprehensive care by skilled healthcare workers in the one visit a woman makes at the health facility, may lead to optimal utilisation of quality focused ANC. Enhancing community-based interventions may increase the potential to reach the vulnerable populations.}, keywords = {Adult, Attitude of Health Personnel, Female, Focus Groups, Health Knowledge, Attitudes, Practice, Health Services Accessibility, Humans, Poverty Areas, Pregnancy, Pregnant Women, Prenatal Care, Qualitative Research, Rural Population, Zambia}, issn = {1472-6963}, doi = {10.1186/s12913-018-3212-9}, author = {Jacobs, Choolwe and Michelo, Charles and Moshabela, Mosa} } @article {1396258, title = {Association between infrastructure and observed quality of care in 4 healthcare services: A cross-sectional study of 4,300 facilities in 8 countries}, journal = {PLoS Med}, volume = {14}, year = {2017}, month = {2017 Dec}, pages = {e1002464}, abstract = {BACKGROUND: It is increasingly apparent that access to healthcare without adequate quality of care is insufficient to improve population health outcomes. We assess whether the most commonly measured attribute of health facilities in low- and middle-income countries (LMICs)-the structural inputs to care-predicts the clinical quality of care provided to patients. METHODS AND FINDINGS: Service Provision Assessments are nationally representative health facility surveys conducted by the Demographic and Health Survey Program with support from the US Agency for International Development. These surveys assess health system capacity in LMICs. We drew data from assessments conducted in 8 countries between 2007 and 2015: Haiti, Kenya, Malawi, Namibia, Rwanda, Senegal, Tanzania, and Uganda. The surveys included an audit of facility infrastructure and direct observation of family planning, antenatal care (ANC), sick-child care, and (in 2 countries) labor and delivery. To measure structural inputs, we constructed indices that measured World Health Organization-recommended amenities, equipment, and medications in each service. For clinical quality, we used data from direct observations of care to calculate providers{\textquoteright} adherence to evidence-based care guidelines. We assessed the correlation between these metrics and used spline models to test for the presence of a minimum input threshold associated with good clinical quality. Inclusion criteria were met by 32,531 observations of care in 4,354 facilities. Facilities demonstrated moderate levels of infrastructure, ranging from 0.63 of 1 in sick-child care to 0.75 of 1 for family planning on average. Adherence to evidence-based guidelines was low, with an average of 37\% adherence in sick-child care, 46\% in family planning, 60\% in labor and delivery, and 61\% in ANC. Correlation between infrastructure and evidence-based care was low (median 0.20, range from -0.03 for family planning in Senegal to 0.40 for ANC in Tanzania). Facilities with similar infrastructure scores delivered care of widely varying quality in each service. We did not detect a minimum level of infrastructure that was reliably associated with higher quality of care delivered in any service. These findings rely on cross-sectional data, preventing assessment of relationships between structural inputs and clinical quality over time; measurement error may attenuate the estimated associations. CONCLUSION: Inputs to care are poorly correlated with provision of evidence-based care in these 4 clinical services. Healthcare workers in well-equipped facilities often provided poor care and vice versa. While it is important to have strong infrastructure, it should not be used as a measure of quality. Insight into health system quality requires measurement of processes and outcomes of care.}, keywords = {Adult, Child, Child Health Services, Cross-Sectional Studies, Developing Countries, Equipment and Supplies, Family Planning Services, Female, Guideline Adherence, Haiti, Health Facilities, Health Personnel, Humans, Infant, Newborn, kenya, Malawi, Maternal Health Services, Namibia, Personnel Staffing and Scheduling, Pharmaceutical Preparations, Practice Guidelines as Topic, Pregnancy, Quality of Health Care, Reproductive Health Services, Rwanda, Senegal, Tanzania, Uganda}, issn = {1549-1676}, doi = {10.1371/journal.pmed.1002464}, author = {Leslie, Hannah H and Sun, Zeye and Margaret E Kruk} } @article {1396260, title = {Effective coverage of primary care services in eight high-mortality countries}, journal = {BMJ Glob Health}, volume = {2}, year = {2017}, month = {2017}, pages = {e000424}, abstract = {Introduction: Measurement of effective coverage (quality-corrected coverage) of essential health services is critical to monitoring progress towards the Sustainable Development Goal for health. We combine facility and household surveys from eight low-income and middle-income countries to examine effective coverage of maternal and child health services. Methods: We developed indices of essential clinical actions for antenatal care, family planning and care for sick children from existing guidelines and used data from direct observations of clinical visits conducted in Haiti, Kenya, Malawi, Namibia, Rwanda, Senegal, Tanzania and Uganda between 2007 and 2015 to measure quality of care delivered. We calculated healthcare coverage for each service from nationally representative household surveys and combined quality with utilisation estimates at the subnational level to quantify effective coverage. Results: Health facility and household surveys yielded over 40 000 direct clinical observations and over 100 000 individual reports of healthcare utilisation. Coverage varied between services, with much greater use of any antenatal care than family planning or sick-child care, as well as within countries. Quality of care was poor, with few regions demonstrating more than 60\% average performance of basic clinical practices in any service. Effective coverage across all eight countries averaged 28\% for antenatal care, 26\% for family planning and 21\% for sick-child care. Coverage and quality were not strongly correlated at the subnational level; effective coverage varied by as much as 20\% between regions within a country. Conclusion: Effective coverage of three primary care services for women and children in eight countries was substantially lower than crude service coverage due to major deficiencies in care quality. Better performing regions can serve as examples for improvement. Systematic increases in the quality of care delivered-not just utilisation gains-will be necessary to progress towards truly beneficial universal health coverage.}, issn = {2059-7908}, doi = {10.1136/bmjgh-2017-000424}, author = {Leslie, Hannah H and Address Malata and Youssoupha Ndiaye and Margaret E Kruk} } @article {1396306, title = {Evaluating and Improving Cardiovascular Health System Management in Low- and Middle-Income Countries}, journal = {Circ Cardiovasc Qual Outcomes}, volume = {10}, year = {2017}, month = {2017 11}, keywords = {Adult, Aged, Cardiovascular Diseases, Cause of Death, Delivery of Health Care, Integrated, Developing Countries, Female, Global Health, Humans, Income, Male, Middle Aged, Models, Organizational, Poverty Areas, Prognosis, Quality Improvement, Quality Indicators, Health Care, Time Factors}, issn = {1941-7705}, doi = {10.1161/CIRCOUTCOMES.117.004292}, author = {Yoo, Sang Gune K and Prabhakaran, Dorairaj and Huffman, Mark D} } @article {1396272, title = {Health system{\textquoteright}s response for physician workforce shortages and the upcoming crisis in Ethiopia: a grounded theory research}, journal = {Hum Resour Health}, volume = {15}, year = {2017}, month = {2017 12 28}, pages = {86}, abstract = {BACKGROUND: A rapid transition from severe physician workforce shortage to massive production to ensure the physician workforce demand puts the Ethiopian health care system in a variety of challenges. Therefore, this study discovered how the health system response for physician workforce shortage using the so-called flooding strategy was viewed by different stakeholders. METHODS: The study adopted the grounded theory research approach to explore the causes, contexts, and consequences (at the present, in the short and long term) of massive medical student admission to the medical schools on patient care, medical education workforce, and medical students. Forty-three purposively selected individuals were involved in a semi-structured interview from different settings: academics, government health care system, and non-governmental organizations (NGOs). Data coding, classification, and categorization were assisted using ATLAs.ti qualitative data analysis scientific software. RESULTS: In relation to the health system response, eight main categories were emerged: (1) reasons for rapid medical education expansion; (2) preparation for medical education expansion; (3) the consequences of rapid medical education expansion; (4) massive production/flooding as human resources for health (HRH) development strategy; (5) cooperation on HRH development; (6) HRH strategies and planning; (7) capacity of system for HRH development; and (8) institutional continuity for HRH development. The demand for physician workforce and gaining political acceptance were cited as main reasons which motivated the government to scale up the medical education rapidly. However, the rapid expansion was beyond the capacity of medical schools{\textquoteright} human resources, patient flow, and size of teaching hospitals. As a result, there were potential adverse consequences in clinical service delivery, and teaching learning process at the present: "the number should consider the available resources such as number of classrooms, patient flows, medical teachers, library{\textellipsis}". In the future, it was anticipated to end in surplus in physician workforce, unemployment, inefficiency, and pressure on the system: "{\textellipsis}flooding may seem a good strategy superficially but it is a dangerous strategy. It may put the country into crisis, even if good physicians are being produced; they may not get a place where to go{\textellipsis}". CONCLUSION: Massive physician workforce production which is not closely aligned with the training capacity of the medical schools and the absorption of graduates in to\ the health system will end up in unanticipated adverse consequences.}, keywords = {Delivery of Health Care, Education, Medical, Emergencies, Ethiopia, Faculty, Medical, Government Programs, Grounded Theory, Health Resources, Health Services, Health Services Accessibility, Health Services Needs and Demand, Hospitals, Teaching, Humans, Organizations, Physicians, Politics, Program Development, Schools, Medical, Stakeholder Participation, Students, Medical, Surveys and Questionnaires, Workforce}, issn = {1478-4491}, doi = {10.1186/s12960-017-0257-5}, author = {Assefa, Tsion and Haile Mariam, Damen and Mekonnen, Wubegzier and Derbew, Miliard} } @article {1396299, title = {{\textquoteright}I am treated well if I adhere to my HIV medication{\textquoteright}: putting patient-provider interactions in context through insights from qualitative research in five sub-Saharan African countries}, journal = {Sex Transm Infect}, volume = {93}, year = {2017}, month = {2017 07}, abstract = {OBJECTIVES: The nature of patient-provider interactions and communication is widely documented to significantly impact on patient experiences, treatment adherence and health outcomes. Yet little is known about the broader contextual factors and dynamics that shape patient-provider interactions in high HIV prevalence and limited-resource settings. Drawing on qualitative research from five sub-Saharan African countries, we seek to unpack local dynamics that serve to hinder or facilitate productive patient-provider interactions. METHODS: This qualitative study, conducted in Kisumu (Kenya), Kisesa (Tanzania), Manicaland (Zimbabwe), Karonga (Malawi) and uMkhanyakude (South Africa), draws upon 278 in-depth interviews with purposively sampled people living with HIV with different diagnosis and treatment histories, 29 family members of people who died due to HIV and 38 HIV healthcare workers. Data were collected using topic guides that explored patient testing and antiretroviral therapy treatment journeys. Thematic analysis was conducted, aided by NVivo V.8.0 software. RESULTS: Our analysis revealed an array of inter-related contextual factors and power dynamics shaping patient-provider interactions. These included (1) participants{\textquoteright} perceptions of roles and identities of {\textquoteright}self{\textquoteright} and {\textquoteright}other{\textquoteright}; (2) conformity or resistance to the {\textquoteright}rules of HIV service engagement{\textquoteright} and a {\textquoteright}patient-persona{\textquoteright}; (3) the influence of significant others{\textquoteright} views on service provision; and (4) resources in health services. We observed that these four factors/dynamics were located in the wider context of conceptualisations of power, autonomy and structure. CONCLUSION: Patient-provider interaction is complex, multidimensional and deeply embedded in wider social dynamics. Multiple contextual domains shape patient-provider interactions in the context of HIV in sub-Saharan Africa. Interventions to improve patient experiences and treatment adherence through enhanced interactions need to go beyond the existing focus on patient-provider communication strategies.}, keywords = {Africa South of the Sahara, Anti-HIV Agents, Directive Counseling, Female, Health Personnel, HIV Infections, Humans, Interviews as Topic, Male, Medication Adherence, Patient-Centered Care, Physician-Patient Relations, Qualitative Research}, issn = {1472-3263}, doi = {10.1136/sextrans-2016-052973}, author = {Ondenge, Ken and Renju, Jenny and Bonnington, Oliver and Moshabela, Mosa and Wamoyi, Joyce and Nyamukapa, Constance and Seeley, Janet and Wringe, Alison and Skovdal, Morten} } @article {1396261, title = {Introducing The Lancet Global Health Commission on High-Quality Health Systems in the SDG Era}, journal = {Lancet Glob Health}, volume = {5}, year = {2017}, month = {2017 05}, pages = {e480-e481}, keywords = {Developing Countries, Global Health, Goals, Humans, Quality of Health Care}, issn = {2214-109X}, doi = {10.1016/S2214-109X(17)30101-8}, author = {Margaret E Kruk and Muhammad Pate and Mullan, Zo{\"e}} } @article {1396292, title = {Performance-based financing to increase utilization of maternal health services: Evidence from Burkina Faso}, journal = {SSM Popul Health}, volume = {3}, year = {2017}, month = {2017 Dec}, pages = {179-184}, abstract = {Performance-based financing (PBF) programs are increasingly implemented in low and middle-income countries to improve health service quality and utilization. In April 2011, a PBF pilot program was launched in Boulsa, Leo and Titao districts in Burkina Faso with the objective of increasing the provision and quality of maternal health services. We evaluate the impact of this program using facility-level administrative data from the national health management information system (HMIS). Primary outcomes were the number of antenatal care visits, the proportion of antenatal care visits that occurred during the first trimester of pregnancy, the number of institutional deliveries and the number of postnatal care visits. To assess program impact we use a difference-in-differences approach, comparing changes in health service provision post-introduction with changes in matched comparison areas. All models were estimated using ordinary least squares (OLS) regression models with standard errors clustered at the facility level. On average, PBF facilities had 2.3 more antenatal care visits (95\% CI [0.446-4.225]), 2.1 more deliveries (95\% CI [0.034-4.069]) and 9.5 more postnatal care visits (95\% CI [6.099, 12.903]) each month after the introduction of PBF. Compared to the service provision levels prior to the interventions, this implies a relative increase of 27.7 percent for ANC, of 9.2 percent for deliveries, and of 118.7 percent for postnatal care. Given the positive results observed during the pre-pilot period and the limited resources available in the health sector, the PBF program in Burkina Faso may be a low-cost, high impact intervention to improve maternal and child health.}, issn = {2352-8273}, doi = {10.1016/j.ssmph.2017.01.001}, author = {Steenland, Maria and Robyn, Paul Jacob and Compaore, Philippe and Kabore, Moussa and Tapsoba, Boukary and Zongo, Aloys and Haidara, Ousmane Diadie and Fink, G{\"u}nther} } @article {1396300, title = {Predictors of Antenatal Care, Skilled Birth Attendance, and Postnatal Care Utilization among the Remote and Poorest Rural Communities of Zambia: A Multilevel Analysis}, journal = {Front Public Health}, volume = {5}, year = {2017}, month = {2017}, pages = {11}, abstract = {OBJECTIVE: Optimal utilization of maternal health-care services is associated with reduction of mortality and morbidity for both mothers and their neonates. However, deficiencies and disparity in the use of key maternal health services within most developing countries still persist. We examined patterns and predictors associated with the utilization of specific indicators for maternal health services among mothers living in the poorest and remote district populations of Zambia. METHODS: A cross-sectional baseline household survey was conducted in May 2012. A total of 551 mothers with children between the ages 0 and 5 months were sampled from 29 catchment areas in four rural and remote districts of Zambia using the lot quality assurance sampling method. Using multilevel modeling, we accounted for individual- and community-level factors associated with utilization of maternal health-care services, with a focus on antenatal care (ANC), skilled birth attendance (SBA), and postnatal care (PNC). RESULTS: Utilization rates of focused ANC, SBA, and PNC within 48 h were 30, 37, and 28\%, respectively. The mother{\textquoteright}s ability to take an HIV test and receiving test results and uptake of intermittent preventive treatment for malaria were positive predictors of focused ANC. Receiving ANC at least once from skilled personnel was a significant predictor of SBA and PNC within 48 h after delivery. Women who live in centralized rural areas were more likely to use SBA than those living in remote rural areas. CONCLUSION: Utilization of maternal health services by mothers living among the remote and poor marginalized populations of Zambia is much lower than the national averages. Finding that women that receive ANC once from a skilled attendant among the remote and poorest populations are more likely to have a SBA and PNC, suggests the importance of contact with a skilled health worker even if it is just once, in influencing use of services. Therefore, it appears that in order for women in these marginalized communities to benefit from SBA and PNC, it is important for them to have at least one ANC provided by a skilled personnel, rather than non-skilled health-care providers.}, issn = {2296-2565}, doi = {10.3389/fpubh.2017.00011}, author = {Jacobs, Choolwe and Moshabela, Mosa and Maswenyeho, Sitali and Lambo, Nildah and Michelo, Charles} } @article {1396259, title = {Service readiness of health facilities in Bangladesh, Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Uganda and the United Republic of Tanzania}, journal = {Bull World Health Organ}, volume = {95}, year = {2017}, month = {2017 Nov 01}, pages = {738-748}, abstract = {Objective: To evaluate the service readiness of health facilities in Bangladesh, Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Uganda and the United Republic of Tanzania. Methods: Using existing data from service provision assessments of the health systems of the 10 study countries, we calculated a service readiness index for each of\ 8443 health facilities. This index represents the percentage availability of 50\ items that the World Health Organization considers essential for providing health care. For our analysis we used 37-49 of the items on the list. We used linear regression to assess the independent explanatory power of four national and four facility-level characteristics on reported service readiness. Findings: The mean values for the service readiness index were 77\% for the 636 hospitals and 52\% for the 7807 health centres/clinics. Deficiencies in medications and diagnostic capacity were particularly common. The readiness index varied more between hospitals and health centres/clinics in the same country than between them. There was weak correlation between national factors related to health financing and the readiness index. Conclusion: Most health facilities in our study countries were insufficiently equipped to provide basic clinical care. If countries are to bolster health-system capacity towards achieving universal coverage, more attention needs to be given to within-country inequities.}, keywords = {Bangladesh, Capacity Building, Equipment and Supplies, Haiti, Health Care Surveys, Health Facilities, kenya, Malawi, Namibia, Nepal, Quality of Health Care, Rwanda, Senegal, Tanzania, Uganda}, issn = {1564-0604}, doi = {10.2471/BLT.17.191916}, author = {Leslie, Hannah H and Spiegelman, Donna and Zhou, Xin and Margaret E Kruk} } @article {1396305, title = {Effectiveness of a Multicomponent Quality Improvement Strategy to Improve Achievement of Diabetes Care Goals: A Randomized, Controlled Trial}, journal = {Ann Intern Med}, volume = {165}, year = {2016}, month = {2016 Sep 20}, pages = {399-408}, abstract = {BACKGROUND: Achievement of diabetes care goals is suboptimal globally. Diabetes-focused quality improvement (QI) is effective but remains untested in South Asia. OBJECTIVE: To compare the effect of a multicomponent QI strategy versus usual care on cardiometabolic profiles in patients with poorly controlled diabetes. DESIGN: Parallel, open-label, pragmatic randomized, controlled trial. (ClinicalTrials.gov: NCT01212328). SETTING: Diabetes clinics in India and Pakistan. PATIENTS: 1146 patients (575 in the intervention group and 571 in the usual care group) with type 2 diabetes and poor cardiometabolic profiles (glycated hemoglobin [HbA1c] level >=8\% plus systolic blood pressure [BP] >=140 mm Hg and/or low-density lipoprotein cholesterol [LDLc] level >=130 mg/dL). INTERVENTION: Multicomponent QI strategy comprising nonphysician care coordinators and decision-support electronic health records. MEASUREMENTS: Proportions achieving HbA1c level less than 7\% plus BP less than 130/80 mm Hg and/or LDLc level less than 100 mg/dL (primary outcome); mean risk factor reductions, health-related quality of life (HRQL), and treatment satisfaction (secondary outcomes). RESULTS: Baseline characteristics were similar between groups. Median diabetes duration was 7.0 years; 6.8\% and 39.4\% of participants had preexisting cardiovascular and microvascular disease, respectively; mean HbA1c level was 9.9\%; mean BP was 143.3/81.7 mm Hg; and mean LDLc level was 122.4 mg/dL. Over a median of 28 months, a greater percentage of intervention participants achieved the primary outcome (18.2\% vs. 8.1\%; relative risk, 2.24 [95\% CI, 1.71 to 2.92]). Compared with usual care, intervention participants achieved larger reductions in HbA1c level (-0.50\% [CI, -0.69\% to -0.32\%]), systolic BP (-4.04 mm Hg [CI, -5.85 to -2.22 mm Hg]), diastolic BP (-2.03 mm Hg [CI, -3.00 to -1.05 mm Hg]), and LDLc level (-7.86 mg/dL [CI, -10.90 to -4.81 mg/dL]) and reported higher HRQL and treatment satisfaction. LIMITATION: Findings were confined to urban specialist diabetes clinics. CONCLUSION: Multicomponent QI improves achievement of diabetes care goals, even in resource-challenged clinics. PRIMARY FUNDING SOURCE: National Heart, Lung, and Blood Institute and UnitedHealth Group.}, keywords = {Blood Pressure, Cholesterol, LDL, Decision Support Systems, Clinical, Diabetes Mellitus, Type 2, Electronic Health Records, Female, Follow-Up Studies, Glycated Hemoglobin A, Humans, India, Male, Middle Aged, Pakistan, Patient Care Team, Quality Improvement, Quality of Life, Risk Factors, Treatment Outcome}, issn = {1539-3704}, doi = {10.7326/M15-2807}, author = {Ali, Mohammed K and Singh, Kavita and Kondal, Dimple and Devarajan, Raji and Patel, Shivani A and Shivashankar, Roopa and Ajay, Vamadevan S and Unnikrishnan, A G and Menon, V Usha and Varthakavi, Premlata K and Viswanathan, Vijay and Dharmalingam, Mala and Bantwal, Ganapati and Sahay, Rakesh Kumar and Masood, Muhammad Qamar and Khadgawat, Rajesh and Desai, Ankush and Sethi, Bipin and Prabhakaran, Dorairaj and Narayan, K M Venkat and Tandon, Nikhil and CARRS Trial Group} } @article {1396273, title = {Physician distribution and attrition in the public health sector of Ethiopia}, journal = {Risk Manag Healthc Policy}, volume = {9}, year = {2016}, month = {2016}, pages = {285-295}, abstract = {BACKGROUND: Shortages and imbalances in physician workforce distribution between urban and rural and among the different regions in Ethiopia are enormous. However, with the recent rapid expansion in medical education training, it is expected that the country can make progress in physician workforce supply. Therefore, the aim of this study was to examine the distribution of physician workforce in Ethiopia and assess the role of retention mechanisms in the reduction of physician migration from the public health sector of Ethiopia. METHODS: This organizational survey examined physician workforce data from 119 hospitals from 5 regions (Amhara, Oromia, Southern Nations Nationalities and Peoples Region [SNNPR], Tigray, and Harari) and 2 city administrations (Addis Ababa and Dire Dawa City). Training opportunity, distribution, and turnover between September 2009 and July 2015 were analyzed descriptively. Poisson regression model was used to find the association of different covariates with physician turnover. RESULTS: There were 2,300 medical doctors in 5 regions and 2 city administrations in ~6 years of observations. Of these, 553 (24.04\%) medical doctors moved out of their duty stations and the remaining 1,747 (75.96\%) were working actively. Of the actively working, the majority of the medical doctors, 1,407 (80.5\%), were males, in which 889 (50.9\%) were born after the year 1985, 997 (57\%) had work experience of \<3 years, and most, 1,471 (84.2\%), were general practitioners. Within the observation period, physician turnover among specialists ranged from 21.4\% in Dire Dawa to 43.3\% in Amhara region. The capital, Addis Ababa, was the place of destination for 32 (82\%) of the physicians who moved out to other regions from elsewhere in the country. The Poisson regression model revealed a decreased incidence of turnover among physicians born between the years 1975 and 1985 (incident rate ratio [IRR]: 0.63; 95\% confidence interval [CI]: 0.51, 0.79) and among those who were born prior to 1975 (IRR: 0.24; 95\% CI: 0.17, 0.34) compared to those who were born after 1985. Female physicians were 1.4 times (IRR: 1.44; 95\% CI: 1.14, 1.81) more likely to move out from their duty stations compared to males. In addition, physicians working in district hospitals were 2 times (IRR: 2.14; 95\% CI: 1.59, 2.89) more likely to move out and those working in general hospitals had 1.39 times (IRR: 1.39; 95\% CI: 1.08, 1.78) increased rate of turnover in comparison with those who were working in referral hospitals. Physicians working in the Amhara region had 2 times (IRR: 2.01; 95\% CI: 1.49, 2.73) increased risk of turnover in comparison with those who were working in the capital, Addis Ababa. The probability of migration did not show a statistically significant difference in all other regions (\>0.05). CONCLUSION: The public health sector physician workforce largely constituted of male physicians, young and less experienced. High turnover rate among females, the young and less experienced physicians, and those working in distant places (district hospitals) indicate the need for special attention in devising human resources management and retention strategies.}, issn = {1179-1594}, doi = {10.2147/RMHP.S117943}, author = {Assefa, Tsion and Haile Mariam, Damen and Mekonnen, Wubegzier and Derbew, Miliard and Enbiale, Wendimagegn} } @article {1416551, title = {Anxiety research in educational psychology}, journal = {J Educ Psychol}, volume = {47}, year = {1979}, month = {1979 Oct}, pages = {573-82}, keywords = {Anxiety, Desensitization, Psychologic, Humans, Learning, memory, Models, Psychological, Relaxation Therapy, Research Design, Teaching}, issn = {0022-0663}, author = {Tobias, S.} } @article {1416561, title = {The purification and properties of NADP-dependent isocitrate dehydrogenase from ox-heart mitochondria}, journal = {Eur J Biochem}, volume = {74}, year = {1977}, month = {1977 Apr 15}, pages = {553-9}, abstract = {The purification of NADP-linked isocitrate dehydrogenase from ox heart mitochondria is described. The molecular weight from gel filtration, sedimentation equilibrium and gel electrophoresis is 90000+/-4000, and there are two subunits in the molecule each of which binds NADPH with enhancement of the coenzyme fluorescence. The amino-acid composition is reported, and the absorption coefficient, A1/280\%, estimated from dry weight measurements is 11.8 cm-1.}, keywords = {Amino Acids, Animals, Cattle, Isocitrate Dehydrogenase, Kinetics, Mitochondria, Muscle, Molecular Weight, Myocardium, NADP, Spectrometry, Fluorescence, Tryptophan}, issn = {0014-2956}, doi = {10.1111/j.1432-1033.1977.tb11424.x}, author = {Macfarlane, N and Mathews, B and Dalziel, K} } @article {1416558, title = {[Comparison of clinical effect and blood concentration of phenylbutazone during long-term treatment]}, journal = {Sem Hop}, volume = {52}, year = {1976}, month = {1976 Sep 10-20}, pages = {1723-4}, keywords = {Adult, Aged, Arthritis, Rheumatoid, Female, Humans, Male, Middle Aged, Phenylbutazone, Spondylitis, Ankylosing}, author = {Gaucher, A and Royer, R J and Netter, P and Royer-Morrot, M J and Faure, G and Pourel, J} } @article {1416562, title = {Letter: Protostreptovaricins I-V}, journal = {J Am Chem Soc}, volume = {98}, year = {1976}, month = {1976 Feb 04}, pages = {870-2}, keywords = {Chemical Phenomena, chemistry, Chromatography, Magnetic Resonance Spectroscopy, Streptovaricin}, issn = {0002-7863}, doi = {10.1021/ja00419a056}, author = {Deshmukh, P V and Kakinuma, K and Ameel, J J and Rinehart, K L and Wiley, P F and Li, L H} } @article {1416560, title = {Properties and development of erythropoietic stem cells in the chick embryo}, journal = {J Embryol Exp Morphol}, volume = {36}, year = {1976}, month = {1976 Oct}, pages = {247-60}, abstract = {1. When injected into irradiated chickens, haemopoietic stem cells give rise to well-defined erythrocytic colonies in the host marrow. Such stem cells (CFU-M = Colony Forming Unit in Marrow) have been found in different tissue of the chicke embryo (yolk sac, blood, marrow). Analysis of the properties of CFU-M reveals that they represent two classes of stem cells: pluripotent stem cells mainly in adult marrow and erythrocytic-committed stem cells present in yolk sac. 2. Yolk sac contains the main pool of CFU-M during the major part of embryonic life. In the blood of 6-day-old embryo, there are three or four times more CFU-Ms than in the yolk sac; they are no longer detected in the blood after the 16th day of incubation. During development of the marrow, stem cells are actively differentiating and their total number remains the same from 16 days to hatching.}, keywords = {Age Factors, Animals, Blood Cell Count, Bone Marrow, Chick Embryo, Erythrocyte Count, Erythrocytes, Female, Hematopoietic Stem Cell Transplantation, Hematopoietic Stem Cells, Tibia, Transplantation, Heterologous, Vitelline Membrane}, issn = {0022-0752}, author = {Samarut, J and Nigon, V} } @article {1416552, title = {Bile acids. XLVII. 12alpha-Hydroxylation of precursors of allo bile acids by rabbit liver microsomes}, journal = {Biochim Biophys Acta}, volume = {409}, year = {1975}, month = {1975 Nov 21}, pages = {249-57}, abstract = {Rabbit liver microsomal preparations fortified with 0.1 mM NADPH effectively promote hydroxylation of [3beta-3H]- or [24-14C]allochenodeoxycholic acid or [5alpha,6alpha-3H2]5alpha-cholestane-3alpha,7alpha-diol to their respective 12alpha-hydroxyl derivatives in yields of about 25 or 65\% in 60 min. Minor amounts of other products are formed from the diol. The requirements for activity of rabbit liver microsomal 12alpha-hydroxylase resemble those of rat liver microsomes. Of a number of enzyme inhibitors studied only p-chloromercuribenzoate demonstrated a marked ability to inhibit the reaction with either tritiated substrate. There was no difference in the quantity of product produced from the tritiated acid or the 14C-labeled acid. No clear sex difference was found in activity of the enzyme, nor was an appreciable difference noted in activity of the enzyme between mature and immature animals.}, keywords = {Aging, Animals, Bile Acids and Salts, Female, Kinetics, Male, Microsomes, Liver, Mixed Function Oxygenases, NADP, Oxidation-Reduction, Rabbits, Sex Factors}, issn = {0006-3002}, doi = {10.1016/0005-2760(75)90159-9}, author = {Ali, S S and Elliott, W H} } @article {1416546, title = {Comparison between procaine and isocarboxazid metabolism in vitro by a liver microsomal amidase-esterase}, journal = {Biochem Pharmacol}, volume = {24}, year = {1975}, month = {1975 Aug 15}, pages = {1517-21}, keywords = {Amidohydrolases, Animals, Esterases, Hydrogen-Ion Concentration, In Vitro Techniques, Isocarboxazid, Kinetics, Male, Metals, Microsomes, Liver, Phospholipids, Procaine, Proteins, Rats, Subcellular Fractions, Temperature}, issn = {1873-2968}, doi = {10.1016/0006-2952(75)90029-5}, author = {Moroi, K and Sato, T} } @article {1416550, title = {Delineation of the intimate details of the backbone conformation of pyridine nucleotide coenzymes in aqueous solution}, journal = {Biochem Biophys Res Commun}, volume = {66}, year = {1975}, month = {1975 Oct 27}, pages = {1173-9}, keywords = {Fourier Analysis, Magnetic Resonance Spectroscopy, Models, Molecular, Molecular Conformation, NAD, NADP, Structure-Activity Relationship, Temperature}, issn = {1090-2104}, doi = {10.1016/0006-291x(75)90482-9}, author = {Bose, K S and Sarma, R H} } @article {1416548, title = {Digitoxin metabolism by rat liver microsomes}, journal = {Biochem Pharmacol}, volume = {24}, year = {1975}, month = {1975 Sep 01}, pages = {1639-41}, keywords = {Animals, Chromatography, Thin Layer, Digitoxigenin, Digitoxin, Hydroxylation, In Vitro Techniques, Male, Microsomes, Liver, NADP, Rats, Time Factors}, issn = {1873-2968}, author = {Schmoldt, A and Benthe, H F and Haberland, G} } @article {1416545, title = {Formate assay in body fluids: application in methanol poisoning}, journal = {Biochem Med}, volume = {13}, year = {1975}, month = {1975 Jun}, pages = {117-26}, keywords = {Aldehyde Oxidoreductases, Animals, Body Fluids, Carbon Dioxide, Formates, Haplorhini, Humans, Hydrogen-Ion Concentration, Kinetics, Methanol, Methods, Pseudomonas}, issn = {0006-2944}, doi = {10.1016/0006-2944(75)90147-7}, author = {Makar, A B and McMartin, K E and Palese, M and Tephly, T R} } @article {1416554, title = {Identification of adenylate cyclase-coupled beta-adrenergic receptors with radiolabeled beta-adrenergic antagonists}, journal = {Biochem Pharmacol}, volume = {24}, year = {1975}, month = {1975 Sep 15}, pages = {1651-8}, keywords = {Adenylyl Cyclases, Adrenergic beta-Antagonists, Alprenolol, Animals, anura, Binding Sites, Catecholamines, Cattle, Cell Membrane, Eels, Erythrocytes, Guinea Pigs, In Vitro Techniques, Isoproterenol, Kinetics, Propranolol, Receptors, Adrenergic, Stereoisomerism, Tritium}, issn = {0006-2952}, doi = {10.1016/0006-2952(75)90001-5}, author = {Lefkowitz, R J} } @article {1416555, title = {Lorazepam in sexual disorders}, journal = {Br J Clin Pract}, volume = {29}, year = {1975}, month = {1975 Jul}, pages = {175-6}, keywords = {Adult, Anti-Anxiety Agents, Anxiety, Clinical Trials as Topic, Female, Humans, Lorazepam, Male, Placebos, Psychotherapy, Sexual Dysfunction, Physiological}, issn = {0007-0947}, author = {Maneksha, S and Harry, T V} } @article {1416553, title = {Metal substitutions incarbonic anhydrase: a halide ion probe study}, journal = {Biochem Biophys Res Commun}, volume = {66}, year = {1975}, month = {1975 Oct 27}, pages = {1281-6}, keywords = {Animals, Binding Sites, Cadmium, Carbonic Anhydrases, Cattle, Humans, Hydrogen-Ion Concentration, Magnetic Resonance Spectroscopy, Mercury, Protein Binding, Protein Conformation, Zinc}, issn = {0006-291X}, doi = {10.1016/0006-291x(75)90498-2}, author = {Smith, R J and Bryant, R G} } @article {1416556, title = {Possible involvement of GABA in the central actions of benzodiazepines}, journal = {Psychopharmacol Bull}, volume = {11}, year = {1975}, month = {1975 Oct}, pages = {58-9}, keywords = {Aminobutyrates, Aminooxyacetic Acid, Animals, Anti-Anxiety Agents, Benzodiazepines, Cats, gamma-Aminobutyric Acid, In Vitro Techniques, Mice, Neurons}, issn = {0048-5764}, author = {Haefely, W and Kulcs{\'a}r, A and M{\"o}hler, H} } @article {1416549, title = {On the problem of oncogene of tumour viruses}, journal = {Acta Virol}, volume = {19}, year = {1975}, month = {1975 Nov}, pages = {501-8}, abstract = {The approach to the problem of oncogenesis of tumorigenic viruses is compared and analyzed from the position of the Altshtein-Vogt hypothesis and from that of the general theory of oncogenesis advanced by the present author. In contrast to the hypothesis of Altshtein-Vogt dealing mainly with the problem of oncogene origin, the general theory of oncogenesis not only defines concretely the origin of the oncogene and the essence of its product, but also makes it possible to understand why, when and how integration of the oncogene with the genome of the cell leads to the transformation of the cell into a benign cell and when into a malignant tumour cell. An analysis of the essence of the "oncogene position effect" from this standpoint shows that an integration, similar in its mechanism but differing in polarity, of the genome of other viruses with the cell genome should lead to the formation of a corresponding antiviral stable (life-long) immunity or also to the emergence of pseudoautoimmune disease of the type caused by "slow" viruses.}, keywords = {Autoimmune Diseases, Cell Transformation, Neoplastic, DNA, Viral, Genetic Code, Humans, Neoplasms, Oncogenic Viruses, RNA, Viral, Transcription, Genetic, Viral Proteins, Virus Replication}, issn = {0001-723X}, author = {Mekler, L B} } @article {1416557, title = {A serum haemagglutinating property dependent upon polycarboxyl groups}, journal = {Br J Haematol}, volume = {29}, year = {1975}, month = {1975 Jan}, pages = {149-56}, abstract = {A serum agglutinin reactive with red cells in the presence of polycarboxyl groups is reported. It is likely that this represents an additional example of the type of agglutinin previously described as agglutinating red cells in the absence of ionized calcium. Experimental evidence is presented indicating that it is free polycarboxyl groups that potentiate agglutination and that any metal ion, such as calcium, capable of chelating with these groups will prove to be inhibitory.}, keywords = {ABO Blood-Group System, Aged, Agglutinins, Antibody Specificity, Carboxylic Acids, Cations, Divalent, Citrates, Edetic Acid, Ficain, Hemagglutination, Humans, Hydrogen-Ion Concentration, Neuraminidase, Papain}, issn = {0007-1048}, doi = {10.1111/j.1365-2141.1975.tb01808.x}, author = {Beck, M L and Freihaut, B and Henry, R and Pierce, S and Bayer, W L} } @article {1416547, title = {V.I. Gavrilov}, journal = {Acta Virol}, volume = {19}, year = {1975}, month = {1975 Nov}, pages = {510}, keywords = {History, 20th Century, USSR, Virology}, issn = {0001-723X} }