Health systems readiness to provide geriatric friendly care services in Uganda: a cross-sectional study

Abstract Background

As ageing emerges as the next public health threat in Africa, there is a paucity of information on how prepared its health systems are to provide geriatric friendly care services. In this study, we explored the readiness of Uganda’s public health system to offer geriatric friendly care services in Southern Central Uganda.

Methods

Four districts with the highest proportion of old persons in Southern Central Uganda were purposively selected, and a cross-section of 18 randomly selected health facilities (HFs) were visited and assessed for availability of critical items deemed important for provision of geriatric friendly services; as derived from World Health Organization’s Age-friendly primary health care centres toolkit. Data was collected using an adapted health facility geriatric assessment tool, entered into Epi-data software and analysed using STATA version 14. Kruskal-Wallis and Dunn’s post hoc tests were conducted to determine any associations between readiness, health facility level, and district.

Results

The overall readiness index was 16.92 (SD ±4.19) (range 10.8–26.6). This differed across districts; Lwengo 17.91 (SD ±3.15), Rakai 17.63 (SD ±4.55), Bukomansimbi 16.51 (SD ±7.18), Kalungu 13.74 (SD ±2.56) and facility levels; Hospitals 26.62, Health centers four (HCIV) 20.05 and Health centers three (HCIII) 14.80. Low readiness was due to poor scores concerning; leadership (0%), financing (0%), human resources (1.7%) and health management information systems (HMIS) (11.8%) WHO building blocks. Higher-level HFs were statistically significantly friendlier than lower-level HFs (p = 0.015). The difference in readiness between HCIIIs and HCIVs was 2.39 (p = 0.025).

Conclusion

There is a low readiness for public health facilities to provide geriatric friendly care services in Uganda. This is due to gaps in all of the health system building blocks. There is a need for health system reforms in Uganda to adequately cater for service provision for older adults if the 2020 global healthy ageing goal is to be met.

Categorías: Investigaciones

Socio-cultural contextual factors that contribute to the uptake of a mobile health intervention to enhance maternal health care in rural Senegal

Abstract Background

Although considerable progress has been made in reducing maternal mortality over the past 25 years in Senegal, the national maternal mortality ratio (MMR), at 315 deaths per 100,000 live births, is still unacceptably high. In recent years a mobile health (mHealth) intervention to enhance maternal health care has been introduced in rural and remote areas of the country. CommCare is an application that runs on cell phones distributed to community health workers known as matrones who enroll and track women throughout pregnancy, birth and the post-partum, offering health information, moral support, appointment reminders, and referrals to formal health care providers.

Methods

An ethnographic study of the CommCare intervention and the larger maternal health program into which it fits was conducted in order to identify key social and cultural contextual factors that contribute to the uptake and functioning of this mHealth intervention in Senegal. Ethnographic methods and semi-structured interviews were used with participants drawn from four categories: NGO field staff (n = 16), trained health care providers (including physicians, nurses, and midwives) (n = 19), community level health care providers (n = 13); and women belonging to a community intervention known as the Care Group (n = 14). Data were analyzed using interpretive analysis informed by critical medical anthropology theory.

Results

The study identified five socio-cultural factors that work in concert to encourage the uptake and use of CommCare: convening women in the community Care Group; a cultural mechanism for enabling pregnancy disclosure; constituting authoritative knowledge amongst women; harnessing the roles of older women; and adding value to community health worker roles. We argue that, while CommCare is a powerful tool of information, clinical support, surveillance, and data collection, it is also a social technology that connects and motivates people, transforming relationships in ways that can optimize its potential to improve maternal health care.

Conclusions

In Senegal, mHealth has the potential not only to bridge the gaps of distance and expertise, but to engage local people productively in the goal of enhancing maternal health care. Successful mHealth interventions do not work as ‘magic bullets’ but are part of ‘assemblages’ – people and things that are brought together to accomplish particular goals. Attention to the social and cultural elements of the global health assemblage within which CommCare functions is critically important to understand and develop this mHealth technology to its full potential.

Categorías: Investigaciones

Implementing the skilled birth attendance strategy in Uganda: a policy analysis

Abstract Background

Uganda, a low resource country, implemented the skilled attendance at birth strategy, to meet a key target of the 5th Millenium Development Goal (MDG), 75% reduction in maternal mortality ratio. Maternal mortality rates remained high, despite the improvement in facility delivery rates. In this paper, we analyse the strategies implemented and bottlenecks experienced as Uganda’s skilled birth attendance policy was rolled out. These experiences provide important lessons for decision makers as they implement policies to further improve maternity care.

Methods

This is a case study of the implementation process, involving a document review and in-depth interviews among key informants selected from the Ministry of Health, Professional Organisations, Ugandan Parliament, the Health Service Commission, the private not-for-profit sector, non-government organisations, and District Health Officers. The Walt and Gilson health policy triangle guided data collection and analysis.

Results

The skilled birth attendance policy was an important priority on Uganda’s maternal health agenda and received strong political commitment, and support from development partners and national stakeholders. Considerable effort was devoted to implementation of this policy through strategies to increase the availability of skilled health workers for instance through expanded midwifery training, and creation of the comprehensive nurse midwife cadre. In addition, access to emergency obstetric care improved to some extent as the physical infrastructure expanded, and distribution of medicines and supplies improved. However, health worker recruitment was slow in part due to the restrictive staff norms that were remnants of previous policies. Despite considerable resources allocated to creating the comprehensive nurse midwife cadre, this resulted in nurses that lacked midwifery skills, while the training of specialised midwives reduced. The rate of expansion of the physical infrastructure outpaced the available human resources, equipment, blood infrastructure, and several health facilities were not fully functional.

Conclusion

Uganda’s skilled birth attendance policy aimed to increase access to obstetric care, but recruitment of human resources, and infrastructural capacity to provide good quality care remain a challenge. This study highlights the complex issues and unexpected consequences of policy implementation. Further evaluation of this policy is needed as decision-makers develop strategies to improve access to skilled care at birth.

Categorías: Investigaciones

Provimento e fixação de médicos na atenção primária à saúde no estado da Bahia

Rev. adm. pública (Online);53(3): 505-519, maio-jun. 2019. tab. [Artigo]

Categorías: Investigaciones

Job satisfaction of the primary healthcare providers with expanded roles in the context of health service integration in rural China: a cross-sectional mixed methods study

Abstract Objective

Against the backdrop of integrating public health services and clinical services at primary healthcare (PHC) institutions, primary healthcare providers (PCPs) have taken on expanded roles. This posed a potential challenge to China as it may directly impact PCPs’ workload, income, and perceived work autonomy, thus affecting their job satisfaction. This study aimed to explore the association between the expanded roles and job satisfaction of the PCPs in township healthcare centers (THCs), the rural PHC institutions in China.

Methods

A cross-sectional study using mixed methods was conducted in 47 THCs in China’s Shandong province. Based on a sample of 1146 PCPs, the association between the proportion of PCPs’ working time spent on public health services and PCPs’ self-reported job satisfaction was estimated using the logistic regression. Qualitative data were also collected and analyzed to explore the mechanism of how the expanded roles impacted PCPs’ job satisfaction.

Results

One hundred eighty-four physicians and 146 nurses undertook increased work responsibilities, accounting for 15.91% and 12.61% of the total sample. For those spending 40–60%, 60–80%, and more than 80% of the working time providing public health services, the time spent on public health was negatively associated with job satisfaction, with the odds ratio being 0.199 [0.067–0.587], 0.083 [0.025–0.276], and 0.030 [0.007–0.130], respectively. Qualitative analysis illustrated that a majority of the PCPs with expanded roles were dissatisfied with their jobs due to the heavy workload, the mismatch between the income and the workload, and the low level of work autonomy. PCPs’ heavier work burden was mainly caused by the current public health service delivery policy and the separation of public health service delivery and regular clinical services delivery, a significant challenge undermining the efforts to better integrate public health services and clinical services at PHC institutions.

Conclusion

The current policies of adding public health service delivery to the PHC system have negative impacts on PCPs’ job satisfaction through increased work responsibilities for PCPs, which have led to low work autonomy and the mismatch between the income and the workload. The fundamental reason lies in the fragmented incentives and external supervision for public health service delivery and clinical service delivery. Policy-makers should balance the development of clinic and public health departments at the institutional level and integrate their financing and supervision at the system level so as to strengthen the synergy of public health service provision and routine clinical service provision.

Categorías: Investigaciones

The Human Resources for Health Program in Rwanda: A Response to Recent Commentaries.

Int J Health Policy Manag;8(7): 459-461, 2019 Apr 17. . [Artigo]

Categorías: Investigaciones

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

Abstract Background

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

Methods

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

Results

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

Conclusions

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

Categorías: Investigaciones

Critical success factors for the successful initiation of Lean in public hospitals in KwaZulu-Natal: a factor analysis and structural equation modelling study

Abstract Background

Lean thinking is one of several operations-management techniques which have yet to be fully embraced in the South African health care sector. In most health care managers’ service delivery mandates, what needs to be done might be known, but it is how it should be done which might be alien to most managers. In order to recognise the “how”, one needs to know the critical success factors for Lean initiation.

Methods

The research took the form of an observational descriptive study with quantitative methods. The objectives were to identify the key variables for the successful initiation of Lean and then to conduct factor analysis and structural equation modelling (SEM) on these variables leading to the identification of critical success factors (CSFs) for Lean initiation. Simple random sampling was applied to select the participants from various categories of 500 senior managers across 73 KwaZulu-Natal (KZN) public hospitals. The sample size was 218, with a response rate of 96.8% (n = 211). For the purpose of identifying key variables for the successful initiation of Lean and then of conducting factor analysis and SEM on these variables, a self-administered, structured questionnaire was used. Data were reduced using exploratory factor analysis (EFA) to identify latent constructs. Confirmatory factor analysis (CFA) was used to determine the reliability and validity of these factors. Structural equation modelling (SEM) fit indices were then applied to assess acceptability of the measurement model.

Results

Certain variables were eliminated during EFA if they cross-loaded onto more than one factor, since this caused discriminant validity problems. In addition, if variables loaded weakly onto a factor, they were not retained. Three critical success factors (CSFs) were identified in this study: strategic leadership and organisational attitude; integration of Lean elements, tools, and techniques; and basic stability in operational processes. All reliability and validity conditions have been met (RMSEA = 0.085; CFI = 0.956 and χ2/df = 2.513), consequently rendering the model reliable and valid.

Conclusion

None of the three CSFs can be viewed in isolation, as they all have significance at different dimensions of capability within the organisation. The use of these CSFs and the context, content, application, and outcome of Lean should be viewed in light of the organisation’s strategic, technical, structural, and cultural environment. Further research in the effectiveness of these CSFs for the rollout of Lean in South African hospitals would be of benefit to the Lean body of knowledge.

Categorías: Investigaciones

The impact of India’s accredited social health activist (ASHA) program on the utilization of maternity services: a nationally representative longitudinal modelling study

Abstract Background

In 2006, the Government of India launched the accredited social health activist (ASHA) program, with the goal to connect marginalized communities to the health care system. We assessed the effect of the ASHA program on the utilization of maternity services.

Methods

We used data from Indian Human Development Surveys done in 2004–2005 and in 2011–2012 to assess demographic and socioeconomic factors associated with the receipt of ASHA services, and used difference-in-difference analysis with cluster-level fixed effects to assess the effect of the program on the utilization of at least one antenatal care (ANC) visit, four or more ANC visits, skilled birth attendance (SBA), and giving birth at a health facility.

Results

Substantial variations in the receipt of ASHA services were reported with 66% of women in northeastern states, 30% in high-focus states, and 16% of women in other states. In areas where active ASHA activity was reported, the poorest women, and women belonging to scheduled castes and other backward castes, had the highest odds of receiving ASHA services. Exposure to ASHA services was associated with a 17% (95% CI 11.8–22.1) increase in ANC-1, 5% increase in four or more ANC visits (95% CI − 1.6–11.1), 26% increase in SBA (95% CI 20–31.1), and 28% increase (95% CI 22.4–32.8) in facility births.

Conclusions

Our results suggest that the ASHA program is successfully connecting marginalized communities to maternity health services. Given the potential of the ASHA in impacting service utilization, we emphasize the need to strengthen strategies to recruit, train, incentivize, and retain ASHAs.

Categorías: Investigaciones

The relationship between gender, parenthood and practice intentions among family medicine residents: cross-sectional analysis of national Canadian survey data

Abstract Background

Family medicine (FM) residents choose among a range of options as they enter practice, including practice model, clinical domains, settings, and populations. The choices they make have implications for primary care workforce planning and may differ between FM residents who are parents and those who are not, as well as between male and female FM residents. We investigate whether parenthood shapes intentions among FM residents entering practice and whether the effect of parenthood differs between male and female FM residents.

Methods

We conducted cross-sectional analysis of national survey data collected from FM residents in Canadian residency programs by the College of Family Physicians of Canada between 2014 and 2017. The survey captures information on intentions for comprehensive or focused practice, practice model, clinical domains, practice setting, and populations. We used chi-square tests and multivariable logistic regression to investigate the relationships between parenthood, gender, and practice intentions, adjusting for other physician personal characteristics.

Results

Almost a quarter of FM residents were parents or became parents during residency. Intentions for the provision comprehensive care were higher among parents, and intentions for clinically focused practice were lower. Differences in intentions for practice models, domains, and settings/population were primarily by gender, though in several cases the effects of parenthood differed between female and male FM residents. Even during residency, the effects of parenthood differ between male and female residents: while three quarters of male parents finish residency in two years, fewer than half of female parents do.

Conclusions

Both parenthood and gender independently shape practice intentions, but the effect of parenthood differs for male and female FM residents. Supporting FM residents who are parents may positively impact the quality and availability of primary care services, especially since parents are more likely to report intentions to provide  comprehensive care soon after entering practice.

Categorías: Investigaciones

Impact of the Umoyo mother-infant pair model on HIV-positive mothers’ social support, perceived stigma and 12-month retention of their HIV-exposed infants in PMTCT care: evidence from a cluster randomized controlled trial in Zambia

Abstract Background

Public health systems in resource-constrained settings have a critical role to play in the elimination of HIV transmission but are often financially constrained. This study is an evaluation of a mother-infant-pair model called “Umoyo,” which was designed to be low cost and scalable in a public health system. Facilities with the Umoyo model dedicate a clinic day to provide services to only HIV-exposed infants (HEIs) and their mothers. Such models are in operation with reported success in Zambia but have not been rigorously tested. This work establishes whether the Umoyo model would improve 12-month retention of HEIs.

Methods

A cluster randomized trial including 28 facilities was conducted across two provinces of Zambia to investigate the impact on 12-month retention of HEIs in care. These facilities were offering Prevention of Mother-to-Child-Transmission (PMTCT) services and supported by the same implementing partner. Randomization was achieved by use of the covariate-constrained optimization technique. Secondary outcomes included the impact of Umoyo clinics on social support and perceived HIV stigma among mothers. For each of the outcomes, a difference-in-difference analysis was conducted at the facility level using the unweighted t test.

Results

From 13 control (12-month retention at endline: 45%) and 11 intervention facilities (12-month retention at endline: 33%), it was found that Umoyo clinics had no impact on 12-month retention of HEIs in the t test (− 11%; 99% CI − 40.1%, 17.2%). Regarding social support and stigma, the un-weighted t test showed no impact though sensitivity tests showed that Umoyo had an impact on increasing social support (0.31; 99% CI 0.08, 0.54) and reducing perceived stigma from health care workers (− 0.27; 99% CI − 0.46, − 0.08).

Conclusion

The Umoyo approach of having a dedicated clinic day for HEIs and their mothers did not improve retention of HEIs though there are indications that it can increase social support among mothers and reduce stigma. Without further support to the underlying health system, based on the evidence generated through this evaluation, the Umoyo clinic day approach on its own is not considered an effective intervention to increase retention of HIV-exposed infants.

Trial registration

Pan African Clinical Trial Registry, ID: PACTR201702001970148. Prospectively registered on 13 January 2017.

Categorías: Investigaciones

Turnover intention of hospital staff in Ontario, Canada: exploring the role of frontline supervisors, teamwork, and mindful organizing

Abstract Background

This study contributes to a small but growing body of literature on how context influences employee turnover intention. We examine the impact of staff perceptions of supervisory leadership support for safety, teamwork, and mindful organizing on turnover intention. Interaction effects of safety-specific constructs on turnover intention are also examined.

Methods

Cross-sectional survey data were collected from nurses, allied health professionals, and unit clerks working in intensive care, general medicine, mental health, or the emergency department of a large community hospital in Southern Ontario.

Results

Hierarchical regression analyses showed that staff perceptions of teamwork were significantly associated with turnover intention (p < 0.001). Direct associations of supervisory leadership support for safety and mindful organizing with turnover intention were non-significant; however, when staff perceived lower levels of mindful organizing at the frontlines, the positive effect of supervisory leadership on turnover intention was significant (p < 0.01).

Conclusions

Our results suggest that, in addition to teamwork perceptions positively affecting turnover intentions, safety-conscious supportive supervisors can help alleviate the negative impact of poor mindful organizing on frontline staff turnover intention. Healthcare organizations should recruit and retain individuals in supervisory roles who prioritize safety and possess adequate relational competencies. They should further dedicate resources to build and strengthen the relational capacities of their supervisory leadership. Moreover, it is important to provide on-site workshops on topics (e.g., conflict management) that can improve the quality of teamwork and consequently reduce employees’ intention to leave their unit/organization.

Categorías: Investigaciones

Integrating community health assistant-driven sexual and reproductive health services in the community health system in Nyimba district in Zambia: mapping key actors, points of integration, and conditions shaping the process

Abstract Introduction

Although large scale public sector community health worker programs have been key in providing sexual and reproductive health (SRH) services in low- and middle-income countries, their integration process into community health systems is not well understood. This study aimed to identify the conditions and strategies through which Community Health Assistants (CHAs) gained entry and acceptability into community health systems to provide SRH services to youth in Zambia. The country’s CHA program was launched in 2010.

Methodology

A phenomenological design was conducted in Nyimba district. All nine CHAs deployed in Nyimba district were interviewed in-depth on their experiences of navigating the introduction of SRH services for youth in community settings, and the data obtained analyzed thematically.

Results

In delivering SRH services targeting youth, CHAs worked with a range of community actors, including other health workers, safe motherhood action groups, community health workers, neighborhood health committees, teachers, as well as political, traditional and religious leaders. CHAs delivered SRH education and services in health facilities, schools, police stations, home settings, and community spaces. They used their health facility service delivery role to gain trust and entry into the community, and they also worked to build relationships with other community level actors by holding regular joint meetings, and acting as brokers between the volunteer health workers and the Ministry of Health. CHAs used their existing social networks to deliver SRH services to adolescents. By embedding the provision of information about SRH into general life skills at community level, the topic’s sensitivity was reduced and its acceptability was enhanced. Further, support from community leaders towards CHA-driven services promoted the legitimacy of providing SRH for youth. Factors limiting the acceptability of CHA services included the taboo of discussing sexuality issues, a gender discriminatory environment, competition with other providers, and challenges in conducting household visits.

Conclusion

Strengthening CHAs’ ability to negotiate and navigate and gain acceptability in the community health system as they deliver SRH, requires support from both the formal health system and community networks. Limitations to the acceptability of CHA-driven SRH services are a product of challenges both in the community and in the formal health system.

Categorías: Investigaciones

Health workforce development and retention in Guinea: a policy analysis post-Ebola.

Hum Resour Health;17(1): 63, 2019 Aug 05. . [Artigo]

Categorías: Investigaciones

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