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What can we learn on public accountability from non-health disciplines: a meta-narrative review.

By S Van Belle and SH Mayhew

Abstract

: Young women who sell sex (YWSS) in Southern Africa are highly vulnerable to HIV, as the risks of being young and female in a high prevalence setting coalesce with those of commercial sex. YWSS are less able to negotiate safe sex, more likely to have higher risk partners, and less likely to use available health services compared to older sex workers. In Zimbabwe\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\'s national HIV programme for sex workers, fewer than 1% of clients were 15-29. We developed monthly interactive workshops for YWSS based on an Activity Pack consisting of 21 sessions organised into six modules. The aim was to encourage YWSS\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\' interaction with each other, build their trust, confidence and skills, and encourage uptake of clinical services. We conducted a process evaluation to assess programme strengths, identify challenges, and recommend changes. This paper presents findings synthesising programme records with qualitative data and discusses feasibility, acceptability, and outputs during the pilot phase. In total, 143 YWSS attended meetings and most were from the target 15-19-year-old age group. Participants enjoyed the sessions and reported improved cooperation, willingness to negotiate with clients, and self-reflection about their futures. Staff found facilitating sessions easy and activities clear and appropriate. Challenges included identifying appropriate referrals, initial recruitment of women in some sites, and managing participants\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\' requests for financial compensation. The number of clients aged 15-19 increased at sex worker clinics in all sites. This programme is the first to target YWSS in Zimbabwe to address their disproportionately low service use. It proved feasible to staff and acceptable to participants over a one-year period. Given enhanced vulnerability of YWSS, this programme provides one workable model for reaching this underserved group.<br/> BACKGROUND: Evaluating clinician compliance with recommended steps in clinical guidelines provides one measure of quality of process of care but can result in a multiplicity of indicators across illnesses, making it problematic to produce any summative picture of process quality, information that may be most useful to policy-makers and managers.<br/> OBJECTIVE: We set out to develop a clinically logical summative measure of the quality of care provided to children admitted to hospital in Kenya spanning the three diagnoses present in 60% or more of admissions that would provide a patient level measure of quality of care in the face of co-morbidity.<br/> METHODS: We developed a conceptual model of care based on three domains: assessment, diagnosis and treatment of illnesses. Individual items within domains correspond to recommended processes of care within national clinical practice guidelines. Summative scores were created to reduce redundancy and enable aggregation across illnesses while maintaining a clear link to clinical domains and our conceptual model. The potential application of the score was explored using data from more than 12,000 children from 8 hospitals included in a prior intervention study in Kenya.<br/> RESULTS: Summative scores obtained from items representing discrete clinical decision points reduced redundancy, aided balance of score contribution across domains, and enabled direct comparison of disease-specific scores and the calculation of scores for children with comorbidity.<br/> CONCLUSION: This work describes the development of a summative Paediatric Admission Quality of Care (PAQC) score measured at the patient level that spans 3 common diseases. The score may be an efficient tool for assessing quality with an ability to adjust for case-mix or other patient level factors if needed. The score principles may have applicability to multiple illnesses and settings. Future analysis will be needed to validate the score. This article is protected by copyright. All rights reserved.<br/> BACKGROUND: There are 285 million people with visual impairment (VI) worldwide including 39 million who are blind; 15 % of those with VI live in Africa, and around 80 % of VI is preventable or treatable with the right equipment, information and skills. The scarcity of human resources for eye health, particularly in Sub-Saharan Africa, is a key challenge towards achieving this goal. Therefore training primary health workers (PHW) in providing eye-care services has been seen by some authors as a way to improve access to eye-care services in remote communities. However, the package of interventions which could be effectively delivered for eye-care at the primary-care level or the set of skills and competencies that PHWs need has not yet been delineated. The aim of the study was to evaluate the effectiveness of a four day training programme of PHWs in primary eye-care conducted in Morogoro, Tanzania in 2010/2011.<br/> METHODS: A mixed methods study using pre- and immediate post-training knowledge assessment of 60 trainees, and in-depth face to face interviews with 20 PHWs and 8 service managers 2 to 3 years after the training.<br/> RESULTS: Pre-and immediate post-training assessments indicated improvement in health worker knowledge about eye-care in the short term. Qualitative investigations 2 to 3 years after the training showed that although staff could make the correct management decisions when presented with eye-health problems, they often could not make a correct diagnosis. PHWs and managers reported satisfaction with the content of the training but some of the less well qualified staff found it overwhelming. Theoretical teaching was appreciated by most participants but almost all suggested increasing the time spent on acquiring skills. The training manual was accepted by many and some improvements were recommended. All interviewed PHWs were keen to improve their skills and knowledge. Acquired skills and knowledge were used for identification, referral of patients and for eye-health promotion.<br/> CONCLUSION: The training program in Morogoro was considered by PHWs as broadly successful and satisfying in terms of content, methods and duration of training. However, any future programme needs to be considered within the context of strengthening wider health systems.<br/> OBJECTIVES: To evaluate the outcomes of the Ponseti manipulation and casting method for clubfoot in a tertiary hospital in Zimbabwe and explore predictors of these outcomes.<br/> METHODS: A cohort study was established of children with idiopathic clubfoot managed from 2011 to 2013 at Parirenyatwa Hospital. Demographic data, clinical features and treatment outcomes were extracted from clinic records. The primary outcome measure was the final Pirani score (clubfoot severity measure) after manipulation and casting. Secondary outcomes included change in Pirani score (pre-treatment to end of casting), number of casts for correction, proportion receiving tenotomy and proportion lost to follow up.<br/> RESULTS: 218 children (337 feet) were eligible for inclusion. The median age at treatment was eight months. 173 children (268 feet) completed casting treatment within the study period. The mean length of time for corrective treatment was 10.2 weeks (9.5 - 10.9 weeks). Of the 45 children who did not complete treatment, 28 were under treatment and 17 were lost to follow-up. A Pirani score of 1 or less was achieved in 85% of feet. Mean Pirani score at presentation was 3.80 (SD 1.15) and post treatment 0.80 (SD 0.56, p-value &lt;0.0001). Severity of deformity and being male were associated with a higher (worse) final Pirani score. Severity and age over two were associated with an increase in the number of casts required to correct deformity.<br/> CONCLUSION: This case series demonstrates that the majority (80%+) of children with clubfoot can achieve a good outcome with the Ponseti manipulation and casting method. This article is protected by copyright. All rights reserved.<br/> OBJECTIVES: The aim of this study was to examine the independent associations between actionable bleeding (AB) and coronary thrombotic events (CTE) on mortality risk after percutaneous coronary intervention (PCI).<br/> BACKGROUND: The independent impact of AB and CTE on mortality risk after PCI remains poorly characterized.<br/> METHODS: A post hoc analysis was conducted of the PARIS (Patterns of Non-Adherence to Dual Antiplatelet Therapy in Stented Patients) registry, a real-world cohort of 5,018 patients undergoing PCI with stent implantation. CTE included definite or probable stent thrombosis or myocardial infarction. AB was defined as Bleeding Academic Research Consortium type 2 or 3. Associations between CTE and AB, both of which were modeled as time-dependent covariates, and 2-year mortality risk were examined using extended Cox regression.<br/> RESULTS: Over 2 years, the cumulative incidence of CTE, AB, and all-cause mortality was 5.9% (n = 289), 8.1% (n = 391), and 4.7% (n = 227), respectively. Adjusted hazard ratios for mortality associated with CTE and AB were 3.3 (95% confidence interval: 2.2 to 4.9) and 3.5 (95% confidence interval: 2.3 to 5.4), respectively. Temporal gradients in risk after either event were highest in the first 30 days and declined rapidly thereafter. Thrombotic events occurring while patients were on versus off dual-antiplatelet therapy were associated with a higher mortality risk, whereas risk related to AB was not influenced by dual-antiplatelet therapy status at the time of bleeding.<br/> CONCLUSIONS: Intracoronary thrombosis and AB are associated with mortality risks of comparable magnitude over a 2-year period after PCI, findings that might inform risk/benefit calculations for extension versus discontinuation of dual-antiplatelet therapy.<br/> OBJECTIVE: In health, accountability has since long been acknowledged as a central issue, but it remains an elusive concept. The literature on accountability spans various disciplines and research traditions, with differing interpretations. There has been little transfer of ideas and concepts from other disciplines to public health and global health. In the frame of a study of accountability of (international) non-governmental organisations in local health systems, we carried out a meta-narrative review to address this gap. Our research questions were: (1) What are the main approaches to accountability in the selected research traditions? (2) How is accountability defined? (3) Which current accountability approaches are relevant for the organisation and regulation of local health systems and its multiple actors?<br/> SETTING: The search covered peer-reviewed journals, monographs and readers published between 1992 and 2012 from political science, public administration, organisational sociology, ethics and development studies. 34 papers were selected and analysed.<br/> RESULTS: Our review confirms the wide range of approaches to the conceptualisation of accountability. The definition of accountability used by the authors allows the categorisation of these approaches into four groups: the institutionalist, rights-based, individual choice and collective action group. These four approaches can be considered to be complementary.<br/> CONCLUSIONS: We argue that in order to effectively achieve public accountability, accountability strategies are to be complementary and synergistic.<br/

Publisher: BMJ Publishing Group
Year: 2016
OAI identifier: oai:researchonline.lshtm.ac.uk:2728733
Provided by: LSHTM Research Online

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