Are health care assistants part of the long-term solution to the nursing workforce deficit in Kenya?

Abstract

This commentary article addresses a critical issue facing Kenya and other Low- and Middle-Income Countries (LMIC): how to remedy deficits in hospitals’ 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.

Categorias: Investigaciones

The current status of gender equity in medicine in Korea: an online survey about perceived gender discrimination

Abstract Background

Although the number of women doctors has increased in South Korea, and efforts to improve gender awareness have gained importance in recent years, the issue of gender equity in the medical field has not been fully evaluated. The aim of this study was to determine the current status of gender equity in the medical profession in Korea.

Methods

An online survey on perceived gender discrimination was conducted for 2 months, with both men and women doctors participating. The results were analyzed using descriptive statistics.

Results

A total of 1170 doctors responded to the survey (9.2% response rate). The survey found that 47.3% of the women respondents and 18.2% of the men had experienced gender discrimination in the resident selection process (P < 0.05), 17.2% of the women and 8.7% of the men had experienced discrimination during the fellowship application process (P < 0.05), and 36.2% of the women and 8.0% of the men had experienced discrimination during the professorship application process (P < 0.05). Both men and women cited the issue of childbirth and parenting as the number one cause of gender discrimination against women doctors.

Conclusions

This study revealed the presence of perceived gender discrimination in the Korean medical society. To address discrimination, a basic approach is necessary to change the working environment so that it is flexible for women doctors, and to change the current culture where the burden of family care, including pregnancy, childbirth, and childcare, is the primary responsibility of women.

Categorias: Investigaciones

Ensuring quality of health workforce education and practice: strengthening roles of accreditation and regulatory systems

Abstract

Regulation of the health workforce and accreditation of educational institutions are intended to protect the public interest, but evidence of the impact of these policies is scarce and occasionally contradictory. The body of research that does exist primarily focuses on policies in the global north and on the major health professions. Stress on accreditation and regulatory systems caused by surges in demand due to the COVID-19 pandemic, privatization of education, rising patient expectations, and emergence of new health worker categories has created urgency for innovation and reform. To understand and evaluate this innovation, we look forward to receiving manuscripts which contribute to the evidence base on the implementation, management, and impact of health worker education and practice regulation, including the intersection of education accreditation and workforce regulation policy. We particularly look forward to manuscripts from underrepresented parts of the globe and underrepresented health workforce sectors that address policy effectiveness, explore different models of regulation, and present innovations that we can all learn from.

Categorias: Investigaciones

Health professional regulation in historical context: Canada, the USA and the UK (19th century to present)

Abstract Background

There is no widespread agreement over what form healthcare professional regulation should take, and the evidence base concerning the effectiveness and fairness of regulatory systems and practices is limited. Those urging policy change argue there is a need to modernize; however, there is much we can learn from reviewing the history of healthcare professional regulation.

Main body

An overview of the history of regulation in Canada, with consideration of the United States of America and the United Kingdom, is provided. Self-regulating professions emerged in the nineteenth century, influenced by a variety of stakeholders responding to local concerns for healthcare quality, access and professional training. Regulatory practices changed over the course of the twentieth and twenty-first centuries in response to changing stakeholders and shifting interests.

Conclusions

Reviewing the history of healthcare professional regulation reveals lessons to inform policy in a range of settings.

Categorias: Investigaciones

Increasing access to health workers in rural and remote areas: what do stakeholders’ value and find feasible and acceptable?

Abstract Background

The primary aim of this study is to assess stakeholders’ views of the acceptability and feasibility of policy options and outcome indicators presented in the 2010 World Health Organization (WHO) global policy recommendations on increasing access to health workers in remote and rural areas through improved retention.

Methods

A survey on the acceptability, feasibility of recruitment and retention policy options, and the importance of their outcome indicators was developed. It followed a cross-sectional approach targeting health workers in rural and remote settings as well as policy- and decision-makers involved in the development of recruitment and retention policies for such areas. Respondents were asked their perception of the importance of the policy outcomes of interest, as well as the acceptability and feasibility of the 2010 WHO guidelines’ policy options using a 9-point Likert scale.

Results

In total, 336 participants completed the survey. Almost a third worked in government; most participants worked in community settings and were involved in the administration and management of rural health workers. Almost all 19 outcomes of interests assessed were valued as important or critical. For the 16 guideline policy options, most were perceived to be "definitely acceptable" and "definitely feasible", although the policy options were generally considered to be more acceptable than feasible.

Conclusion

The findings of this study provide insight into the revision and update of the 2010 WHO guideline on increasing access to health workers in remote and rural areas. Stakeholders’ views of the acceptability, feasibility of policy options and the importance of outcomes of interest are important for the development of relevant and effective policies to improve access to health workers in rural and remote areas.

Categorias: Investigaciones

The association between the workload of general practitioners and patient experiences with care: results of a cross-sectional study in 33 countries

Abstract Background

The workload of general practitioners (GPs) and dissatisfaction with work have been increasing in various Western countries over the past decades. In this study, we evaluate the relation between the workload of GPs and patients’ experiences with care.

Methods

We collected data through a cross-sectional survey among 7031 GPs and 67,873 patients in 33 countries. Dependent variables are the patient experiences on doctor-patient communication, accessibility, continuity, and comprehensiveness of care. Independent variables concern the workload measured as the GP-reported work hours per week, average consultation times, job satisfaction (an indicator of subjective workload), and the difference between the workload measures of every GP and the average in their own country. Finally, we evaluated interaction effects between workload measures and what patients find important in a country and the presence of a patient-list system. Relationships were determined through multilevel regression models.

Results

Patients of GPs who are happier with their work were found to experience better communication, continuity, access, and comprehensiveness. When GPs are more satisfied compared to others in their country, patients also experience better quality. When GPs work more hours per week, patients also experience better quality of care, but not in the area of accessibility. A longer consultation time, also when compared to the national average, is only related to more comprehensive care. There are no differences in the relationships between countries with and without a patient list system and in countries where patients find the different quality aspects more important.

Conclusions

Patients experience better care when their GP has more work hours, longer consultation times, and especially, a higher job satisfaction.

Categorias: Investigaciones

In-service nurse mentoring in 2020, the year of the nurse and the midwife: learning from Bihar, India.

In-service nurse mentoring is increasingly seen as a way to strengthen the quality of health care in rural areas, where healthworkers are scarce. Despite this, the evidence base for designing large-scale programs remains relatively thin. In this capacity-building article, we reflect on the limited evidence that exists and introduce features of the world's largest program, run by CARE-India since 2015. Detail on the mechanics of large-scale programs is often missing from empirical research studies, but is a crucial aspect of organizational learning and development. Moreover, by focusing on the complex ways in which capacity-building is being institutionalized through an embedded model of in-service mentorship, this article bridges research and practice. We point to a number of areas that require further research as well as considerations for program managers designing comparable workforce strengthening programs. With careful planning and cross-national policy learning, we propose that in-service nurse mentoring may offer a cost-effective and appropriate workforce development approach in a variety of settings.
Categorias: Investigaciones

Implementing social accountability for contraceptive services: lessons from Uganda

Abstract Background

Growing evidence shows that social accountability contributes to improving health care services, with much promise for addressing women’s barriers in contraceptive care. Yet little is known about how social accountability works in the often-complex context of sexual and reproductive health, particularly as sex and reproduction can be sensitive topics in the open and public formats typical of social accountability. This paper explores how social accountability operates in the highly gendered and complex context of contraceptive care.

Methods

This exploratory research uses a case study approach to provide a more grounded understanding of how social accountability processes operate in the context of contraceptive information and services. We observed two social accountability projects that predominantly focused on contraceptive care in Uganda over a year. Five instruments were used to capture information from different source materials and multiple respondents. In total, one hundred and twenty-eight interviews were conducted and over 1000 pages of project documents were collected. Data were analyzed and compiled into four case studies that provide a thick description of how these two projects operated.

Results

The case studies show the critical role of information, dialogue and negotiation in social accountability in the context of contraceptive care. Improved community and health system relationships, community empowerment, provider and health system responsiveness and enhanced availability and access to services were reported in both projects. There were also changes in how different actors related to themselves and to each other, and contraceptive care, a previously taboo topic, became a legitimate area for public dialogue.

Conclusion

The study found that while social accountability in the context of contraceptive services is indeed sensitive, it can be a powerful tool to dissolving resistance to family planning and facilitating a more productive discourse on the topic.

Categorias: Investigaciones

Leveraging Technology to Enable Effective Preventive Screening of NCDs at Population Scale: Initial Observations

Abstract

India is undergoing an epidemiological transition to non-communicable diseases (NCDs), with NCDs contributing to nearly 60 percent of all deaths in India. NCDs are challenging to manage given their silent onset, low health awareness, significant informational asymmetry, and low health-seeking behavior among the rural population and the poor in India. The Ministry of Health and Family Welfare (MoHFW), Government of India, launched Ayushman Bharat to move from a sectoral and segmented approach of health service delivery to a more comprehensive one. As part of this effort, a program was launched for population-based screening (PBS) and management of five common NCDs—hypertension, diabetes, oral, breast, and cervical cancers. The success of the program, among other things, will be determined largely by the early detection, timely treatment, and diligent follow-ups to manage the five NCDs. In line with WHO’s Global action plan for the prevention and control of NCDs 2013–2020, India is the first country to develop specific national targets and indicators aimed at reducing the number of global premature deaths from NCDs by 25% by 2025. However, challenges like human resource shortfall, limited capacities of the health workers, heavy burden of managing multiple health priorities, and poor utilization of public health facilities may affect the outcomes of this ambitious initiative Technology can serve as an enabler in solving some of these problems. Dell Technologies and Tata Trusts have partnered with the Ministry of Health and Family Welfare, Government of India, to develop a technology solution for the PBS NCD initiative. It consists of a suite of mobile and web apps on a cloud platform for health workers, doctors, and health administrators to enable care delivery for people across the country. The solution has been deployed in states across the country with adoption gaining momentum amongst health care providers. While early process indicators are encouraging, it is important to examine individual clinical outcomes, population outcomes and cost effectiveness which are the primary objectives of such a program. The learnings from this digital health program can then be transposed to similar healthcare settings. The paper covers four challenges commonly encountered in the context of running large-scale digital health programs in a multi-state, multi-facility, and multi-stakeholder system. These are adoption of technology by health workers with low digital literacy, feasibility of running tech solutions in remote areas, value proposition of the solution for users and finally the know-how on building and rolling-out technology at scale to reach millions of people.

Categorias: Investigaciones

Maternal and newborn care during the COVID-19 pandemic in Kenya: re-contextualising the community midwifery model

Abstract

Peripartum deaths remain significantly high in low- and middle-income countries, including Kenya. The COVID-19 pandemic has disrupted essential services, which could lead to an increase in maternal and neonatal mortality and morbidity. Furthermore, the lockdowns, curfews, and increased risk for contracting COVID-19 may affect how women access health facilities. SARS-CoV-2 is a novel coronavirus that requires a community-centred response, not just hospital-based interventions. In this prolonged health crisis, pregnant women deserve a safe and humanised birth that prioritises the physical and emotional safety of the mother and the baby. There is an urgent need for innovative strategies to prevent the deterioration of maternal and child outcomes in an already strained health system. We propose strengthening community-based midwifery to avoid unnecessary movements, decrease the burden on hospitals, and minimise the risk of COVID-19 infection among women and their newborns.

Categorias: Investigaciones

Regulation, migration and expectation: internationally qualified health practitioners in Australia—a qualitative study

Abstract Background

The global movement of internationally qualified health practitioners (IQHPs), seeking to live and work outside of their place of origin, is subject to considerable study and scrutiny. Extensive published material exists, from government enquiries and print news media articles to peer-reviewed papers, reporting on the views and impacts of migration and practitioner registration. Unsurprisingly much of the research focuses on the two largest groups of health professionals, international medical graduates (IMG) and internationally qualified nurses (IQN). This paper presents a unique case study examining the challenges and complexities of navigating the regulatory processes for skilled migration and practitioner registration in Australia.

Discussion

The study comprised a review and analysis of the current policy frameworks, standards and assessment models applied by regulators affecting skilled migration and registration of IQHPs. To target the triangulated themes of regulation, experience and expectations, a phenomenological component was also conducted with the mapping of shared experiences of four key participant groups comprising the following: assessors operationalising the current policies and processes governing skilled migration and registration, educators offering preparatory and training programs to IQHP, workforce agencies engaging with and recruiting IQHP and internationally qualified doctors, nurses and midwives. The study was informed by rich qualitative data extracted from twenty-eight in-depth semi-structured participant interviews. Key themes and points of intersection between participant experiences and the regulatory frameworks were identified using theory and data-driven coding and thematic analysis via the NVivo 12 plus software.

Conclusion

From studying the complexities of the current regulatory processes for skilled migration and practitioner registration and informed by participants with first-hand knowledge and experience, this research found a clear argument for a re-examination and update of the current regulatory requirements for IQHP. Without greater innovation, harmonisation, evidence-based solutions and reform, it is likely that Australian regulators, policymakers, employers, and the nursing, midwifery and medical professions at large will continue to experience challenges in registering, employing and supporting IQHP, while maintaining the safety of the public requiring care in the Australian healthcare system.

Categorias: Investigaciones

Experiences of a new cadre of midwives in Bangladesh: findings from a mixed method study

Abstract Background

Bangladesh did not have dedicated professional midwives in public sector health facilities until recently, when the country started a nation-wide programme to educate and deploy diploma midwives. The objective of the findings presented in this paper, which is part of a larger study, was to better understand the experience of the midwives of their education programme and first posting as a qualified midwife and to assess their midwifery knowledge and skills.

Methods

We applied a mixed method approach, which included interviewing 329 midwives and conducting 6 focus group discussions with 43 midwives and midwifery students. Sampling weights were used to generate representative statistics for the entire cohort of the midwives deployed in the public sector health facilities.

Results

Most of the midwives were satisfied with different dimensions of their education programme, with the exception of the level of exposure they had to the rural communities during their programme. Out of 329 midwives, 50% received tuition fee waivers, while 46% received funding for educational materials and 40% received free accommodation. The satisfaction with the various aspects of the current posting was high and nearly all midwives reported that a desire to work in the public sector in the long run. However, a significant proportion of the midwives expressed concerns with equipment, accommodation, transport and prospect of transfers. The scores on the knowledge test and self-reported skill levels were varied but reasonably high.

Conclusion

While the midwives are highly motivated, satisfied with many aspects of their current jobs and have adequate knowledge and skills, there are some bottlenecks and concerns that, if unaddressed, may derail the success of this programme. To capture the career progress of these midwives, additional research, including a follow-up study with the same cohort of midwives, would be beneficial to this programme.

Categorias: Investigaciones

Condiciones y medio ambiente de trabajo en salud: modelo conceptual para áreas remotas y rurales

Se propone un modelo conceptual sobre condiciones y medio ambiente de trabajo en salud que integra la evidencia disponible para facilitar el diseño y la evaluación de intervenciones orientadas a mejorar la atracción, captación y retención del personal de salud en el primer nivel de atención de áreas rurales y remotas. Se consultó la evidencia teórica, empírica y testimonial para fundamentar la propuesta y se sintetizaron 15 modelos difundidos en los últimos 20 años. El artículo da cuenta de la diversidad de perspectivas y la complejidad que conlleva establecer las dimensiones que deben considerarse en una propuesta que sea útil para aplicar a las políticas de recursos humanos en salud. El modelo propuesto incluye cuatro categorías de componentes: factores del contexto externo, factores organizacionales, condiciones del empleo y del trabajo, y factores individuales. Los límites entre los componentes –así como el peso y la influencia de cada uno– varían en función de la relación entre ellos y de la interacción con el medio, por lo que su interpretación debe adecuarse al ámbito en que se pretenda aplicar. A partir de este modelo conceptual, el diseño y la evaluación de las intervenciones dirigidas a incrementar la disponibilidad de personal de salud –en particular en el primer nivel de atención de áreas rurales y remotas de la Región de las Américas– deberían surgir de una interacción entre las políticas de salud y empleo, y las realidades y expectativas de los trabajadores y las comunidades. This report proposes a conceptual model on workplace environment and working conditions that integrates the available evidence to facilitate the design and evaluation of interventions aimed at improving the attraction, recruitment and retention of health personnel at the first level of care in rural and remote areas. Theoretical, empirical and testimonial evidence was consulted to support the model, and 15 frameworks disseminated in the last 20 years were synthesized. The article shows the diversity of perspectives and the complexity involved in establishing the dimensions to be considered in a proposal that is useful to apply to human resources for health policies. The proposed model includes four categories of components: factors of the external context, organizational factors, employment and work conditions, and individual factors. The boundaries between the components – as well as the weight and influence of each one– vary according to the interrelationship among them and the interaction with the environment, and thus its interpretation must be adapted to the context in which it is intended to be applied. Based on this conceptual model, the design and evaluation of interventions aimed at increasing the availability of health personnel –particularly at the primary care level in rural and remote areas of the Region of the Americas– should emerge from an interaction between health and employment policies, and the realities and expectations of workers and the communities.
Categorias: Investigaciones

Confronting power in low places: historical analysis of medical dominance and role-boundary negotiation between health professions in Nigeria.

INTRODUCTION: Interprofessional interaction is intrinsic to health service delivery and forms the basis of task-shifting and task-sharing policies to address human resources for health challenges. But while interprofessional interaction can be collaborative, professional hierarchies and discipline-specific patterns of socialisation can result in unhealthy rivalry and conflicts which disrupt health system functioning. A better understanding of interprofessional dynamics is necessary to avoid such negative consequences. We, therefore, conducted a historical analysis of interprofessional interactions and role-boundary negotiations between health professions in Nigeria. METHODS: We conducted a review of both published and grey literature to provide historical accounts and enable policy tracing of reforms related to interprofessional interactions. We used Nancarrow and Borthwick's typology for thematic analysis and used medical dominance and negotiated order theories to offer explanations of the conditions that facilitated or constrained interprofessional collaboration. RESULTS: Despite an overall context of medical dominance, we found evidence of professional power changes (dynamics) and role-boundary shifts between health professions. These shifts occurred in different directions, but shifts between professions that are at different power gradients were more likely to be non-negotiable or conflictual. Conditions that facilitated consensual role-boundary shifts included the feasibility of simultaneous upward expansion of roles for all professions and the extent to which the delegating profession was in charge of role delegation. While the introduction of new medical diagnostic technology opened up occupational vacancies which facilitated consensual role-boundary change in some cases, it constrained professional collaboration in others. CONCLUSIONS: Health workforce governance can contribute to better functioning of health systems and voiding dysfunctional interprofessional relations if the human resource for health interventions are informed by contextual understanding (informed by comparative institutional and health systems research) of conditions that facilitate or constrain effective interprofessional collaboration.
Categorias: Investigaciones

Opportunities and challenges to integrating mental health into HIV programs in a low- and middle-income country: insights from the Nigeria implementation science Alliance

Abstract Background

In Nigeria, there is an estimated 1.9 million people living with HIV (PLHIV), 53% of whom utilize HIV care and services. With decreasing HIV-related deaths and increasing new infections, HIV with its associated comorbidities continue to be a key public health challenge in Nigeria. Untreated, comorbid mental disorders are a critical but potentially modifiable determinant of optimal HIV treatment outcomes.

This study aimed to identify the challenges and opportunities related to integrating mental health care into existing HIV programs in Nigeria.

Method

Attendees at the Nigeria Implementation Science Alliance (NISA)‘s 2019 conference participated in nominal group technique (NGT) exercise informed by the “Exploration, Preparation, Implementation, and Sustainment (EPIS)” framework. The NGT process was conducted among the nominal groups in two major sessions of 30-min phases followed by a 30-min plenary session. Data analysis proceeded in four steps: transcription, collation, theming and content analysis.

Results

The two major theoretical themes from the study were – opportunities and challenges of integrating mental health treatment into HIV services. Three sub-themes emerged on opportunities: building on health care facilities for HIV services (screening, counseling, task-sharing monitoring and evaluation frameworks), utilizing existing human resources or workforce in HIV programs (in-service training and including mental health in education curriculum) and the role of social and cultural structures (leveraging existing community, traditional and faith-based infrastructures). Four sub-themes emerged for challenges: double burden of stigma and the problems of early detection (HIV and mental health stigma, lack of awareness), existing policy gaps and structural challenges (fragmented health system), limited human resources for mental health care in Nigeria (knowledge gap and burnout) and dearth of data/evidence for planning and action (research gaps).

Conclusions

Potential for integrating treatments for mental disorders into HIV programs and services exist in Nigeria. These include opportunities for clinicians’ training and capacity building as well as community partnerships. Multiple barriers and challenges such as stigma, policy and research gaps would need to be addressed to leverage these opportunities. Our findings serve as a useful guide for government agencies, policy makers and research organizations to address co-morbid mental disorders among PLHIV in Nigeria.

Categorias: Investigaciones

Tracking health sector priority setting processes and outcomes for human resources for health, five-years after political devolution: a county-level case study in Kenya.

BACKGROUND: Health sector priority setting in Low and Middle-Income Countries (LMICs) entails balancing between a high demand and low supply of scarce resources. Human Resources for Health (HRH) consume the largest allocation of health sector resources in LMICs. Health sector decentralization continues to be promoted for its perceived ability to improve efficiency, relevance and participation in health sector priority setting. Following the 2013 devolution in Kenya, both health service delivery and human resource management were decentralized to county level. Little is known about priority setting practices and outcomes of HRH within decentralized health systems in LMICs. Our study sought to examine if and how the Kenyan devolution has improved health sector priority setting practices and outcomes for HRH. METHODS: We used a mixed methods case study design to examine health sector priority setting practices and outcomes at county level in Kenya. We used three sources of data. First, we reviewed all relevant national and county level policy and guidelines documents relating to HRH management. We then accessed and reviewed county records of HRH recruitment and distribution between 2013 and 2018. We finally conducted eight key informant interviews with various stakeholder involved in HRH priority setting within our study county. RESULTS: We found that HRH numbers in the county increased by almost two-fold since devolution. The county had two forms of HRH recruitment: one led by the County Public Services Board as outlined by policy and guidelines and a parallel, politically-driven recruitment done directly by the County Department of Health. Though there were clear guidelines on HRH recruitment, there were no similar guidelines on allocation and distribution of HRH. Since devolution, the county has preferentially staffed higher level hospitals over primary care facilities. Additionally, there has been local county level innovations to address some HRH management challenges, including recruiting doctors and other highly specialized staff on fixed term contract as opposed to permanent basis; and implementation of local incentives to attract and retain HRH to remote areas within the county. CONCLUSION: Devolution has significantly increased county level decision-space for HRH priority setting in Kenya. However, HRH management and accountability challenges still exist at the county level. There is need for interventions to strengthen county level HRH management capacity and accountability mechanisms beyond additional resources allocation. This will boost the realization of the country's efforts for promoting service delivery equity as a key goal - both for the devolution and the country's quest towards Universal Health Coverage (UHC).
Categorias: Investigaciones

Exploring the role of shift work in the self-reported health and wellbeing of long-term and assisted-living professional caregivers in Alberta, Canada

Abstract Background

Numerous studies have found negative outcomes between shift work and physical, emotional, and mental health. Many professional caregivers are required to work shifts outside of the typical 9 am to 5 pm workday. Here, we explore whether shift work affects the health and wellbeing of long-term care (LTC) and assisted-living (AL) professional caregivers.

Method

The Caring for Professional Caregivers research study was conducted across 39 LTC and AL facilities in Alberta, Canada. Of the 1385 questionnaires distributed, 933 surveys (67.4%) were returned completed. After identifying 49 questions that significantly explained variances in the reported health status of caregivers, we examined whether there was a relationship between these questions and reported health status of caregivers working night shifts.

Results

We found significant differences between responses from those working different shifts across six of seven domains, including physical health, health conditions, mental/emotional health, quality of life, and health behaviors. In particular, we found that night shift caregivers were more likely to report incidents of poor heath (i.e., they lacked energy, had regular presences of neck and back pain, regular or infrequent incidents of fatigue or low energy, had difficulty falling asleep, and that they never do exercise) and less likely to report incidents of good health (i.e., did not expect their health to improve, were not satisfied with their health, do not have high self-esteem/were happy, were unhappy with their physical appearance, and do not get a good night’s sleep), compared to caregivers working other shifts.

Conclusions

Our study shows that professional caregivers working the night shift experience poor health status, providing further evidence that night shift workers’ health is at risk. In particular, caregivers reported negative evaluations of their physical, mental/emotional health, lower ratings of their quality of life, and negative responses to questions concerning whether they engage in healthy behaviors. Our findings can support healthcare stakeholders outline future policies that ensure caregivers are adequately supported so that they provide quality care.

Categorias: Investigaciones

Determinants for choice of home birth over health facility birth among women of reproductive age in Tanzania: an analysis of data from the 2015-16 Tanzania demographic and health survey and malaria indicator survey

Abstract Background

While evidence has shown an association between place of birth and birth outcomes, factors contributing to the choice of home birth have not been adequately investigated in Tanzania while more than 30% of deliveries occur outside of health care facilities, and more than 95% of those deliveries are assisted by non-medical providers who are often unskilled. The use of unskilled birth attendants has been cited as a factor contributing to the high maternal and neonatal mortalities in low-resources countries. This study aimed to identify determinants of choice for home birth over health care facility birth in Tanzania.

Method:

This study used the 2015-16 Tanzania Demographic and Health Survey and Malaria Indicator Survey (2015-16 TDHS-MIS) dataset. A total of 2286 women of reproductive age (15–49 years) who gave birth within one year preceding the survey were included in the analysis. Both univariate and multivariable regression analyses were used to determine predictors for the choice of home-based childbirth over health care facility delivery.

Results

A total of 805 (35.2%) women had a home birth. After adjusting for confounders, the determinants for choice of home birth were: the level of education (primary education [AOR = 0.666; p = 0.001]; secondary and higher education [AOR = 0.417; p < 0.001]), in reference to no formal education; not owning a mobile phone (AOR = 1.312; p = 0.018); parity (parity 2–4 [AOR = 1.594; p = 0.004], parity 5 and above [AOR = 2.158; p < 0.001] in reference to parity 1); inadequate antenatal visits (AOR = 1.406; p = 0.001); wealth index (poorest (AOR = 9.395, p < 0.001); poorer (AOR = 7.701; p < 0.001); middle (AOR = 5.961; p < 0.001); richer (AOR = 2.557; p < 0.001)] in reference to richest women; and Zones (Southern Highlands, [AOR = 0.189; p < 0.001]; Southern, [AOR = 0.225; p < 0.001]; Zanzibar, [AOR = 2.55; p < 0.001]) in reference to Western zone.

Conclusions

A large proportion of women birth at home. Unskilled providers such as traditional birth attendants (TBAs), relatives or friends attend most of them. Predictors for home-based childbirth included lack of formal education, poor access to telecommunication, poor uptake of antenatal visits, low socio-economic status, and geographical zone. Innovative strategies targeting these groups are needed to increase the use of health care facilities for childbirth, thereby reducing maternal and neonatal mortality in Tanzania.

Categorias: Investigaciones

Impact of the Programa Mais médicos (more doctors Programme) on primary care doctor supply and amenable mortality: quasi-experimental study of 5565 Brazilian municipalities.

BACKGROUND: Investing in human resources for health (HRH) is vital for achieving universal health care and the Sustainable Development Goals. The Programa Mais Médicos (PMM) (More Doctors Programme) provided 17,000 doctors, predominantly from Cuba, to work in Brazilian primary care. This study assesses whether PMM doctor allocation to municipalities was consistent with programme criteria and associated impacts on amenable mortality. METHODS: Difference-in-differences regression analysis, exploiting variation in PMM introduction across 5565 municipalities over the period 2008-2017, was employed to examine programme impacts on doctor density and mortality amenable to healthcare. Heterogeneity in effects was explored with respect to doctor allocation criteria and municipal doctor density prior to PMM introduction. RESULTS: After starting in 2013, PMM was associated with an increase in PMM-contracted primary care doctors of 15.1 per 100,000 population. However, largescale substitution of existing primary care doctors resulting in a net increase of only 5.7 per 100,000. Increases in both PMM and total primary care doctors were lower in priority municipalities due to lower allocation of PMM doctors and greater substitution effects. The PMM led to amenable mortality reductions of - 1.06 per 100,000 (95%CI: - 1.78 to - 0.34) annually - with greater benefits in municipalities prioritised for doctor allocation and where doctor density was low before programme implementation. CONCLUSIONS: PMM potential health benefits were undermined due to widespread allocation of doctors to non-priority areas and local substitution effects. Policies seeking to strengthen HRH should develop and implement needs-based criteria for resource allocation.
Categorias: Investigaciones

The evidence gap on gendered impacts of performance-based financing among family physicians for chronic disease care: a systematic review reanalysis in contexts of single-payer universal coverage

Abstract Background

Although pay-for-performance (P4P) among primary care physicians for enhanced chronic disease management is increasingly common, the evidence base is fragmented in terms of socially equitable impacts in achieving the quadruple aim for healthcare improvement: better population health, reduced healthcare costs, and enhanced patient and provider experiences. This study aimed to assess the literature from a systematic review on how P4P for diabetes services impacts on gender equity in patient outcomes and the physician workforce.

Methods

A gender-based analysis was performed of studies retrieved through a systematic search of 10 abstract and citation databases plus grey literature sources for P4P impact assessments in multiple languages over the period January 2000 to April 2018, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The study was restricted to single-payer national health systems to minimize the risk of physicians sorting out of health organizations with a strong performance pay component. Two reviewers scored and synthesized the integration of sex and gender in assessing patient- and provider-oriented outcomes as well as the quality of the evidence.

Findings

Of the 2218 identified records, 39 studies covering eight P4P interventions in seven countries were included for analysis. Most (79%) of the studies reported having considered sex/gender in the design, but only 28% presented sex-disaggregated patient data in the results of the P4P assessment models, and none (0%) assessed the interaction of patients’ sex with the policy intervention. Few (15%) of the studies controlled for the provider’s sex, and none (0%) discussed impacts of P4P on the work life of providers from a gender perspective (e.g., pay equity).

Conclusions

There is a dearth of evidence on gender-based outcomes of publicly funded incentivizing physician payment schemes for chronic disease care. As the popularity of P4P to achieve health system goals continues to grow, so does the risk of unintended consequences. There is a critical need for research integrating gender concerns to help inform performance-based health workforce financing policy options in the era of the Sustainable Development Goals.

Categorias: Investigaciones

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