Globalization, Health Sector Reform, Gender and Reproductive Health

Explores the interrelationships between globalization and health sector reforms, and how changes in macro-economic and social policies affect women's reproductive health and rights

Patient involvement in quality improvement in primary health care

A Thesis submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in fulfilment of the requirements for the degree of Doctor of Philosophy December 2015 Johannesburg.Introduction There has been little published in South Africa regarding quality improvement in health and in particular the involvement of patients in this intervention. There is evidence globally that both quality improvement efforts and particularly the engagement of the users adds value to health services. Three projects were conceived around this core concept as explained below. 1. Systematic review. Patients’ involvement in improvement initiatives: a qualitative systematic review After a search was done of databases, 5121 papers were found to be potentially relevant. After screening and critical appraisal for eligibility, it was found that 31 articles qualified for analysis. These were then assessed using JBI software and 5 categories and 2 metasynthesised findings were documented. In summary, there were enablers and barriers to involving patients. The five categories which lead to these 2 findings were the following: (1) although patient participation in QI is acknowledged and encouraged by many policies and documents globally, it is difficult to implement; (2) there are differing views between patients and providers as to the process; (3) on the positive side, different levels of involvement of patients in QI were demonstrated; 4) practical, appropriate and innovative results emerged; (5) individual or group support and incremental development through skills and enablement contributed towards success 2. The Integration of Non Communicable Chronic Diseases (NCDs) and HIV/Aids and mental health care through the involvement of chronically ill patients using Empowerment Evaluation (EE). At 9 primary care clinics, the process of EE was followed with chronically ill stable patients and appropriate healthcare workers. This was an additional intervention in an ongoing QI cycle on the integration of all chronic illnesses into one model, based on Lean principles. Steps followed were ‘’taking stock’’ ie assessing patients’ and HCWs’ impressions of the services at the clinic in a measured way, creating a vision and using this as a yardstick for the project and then problems and solutions being co-managed by the collaborative team. A total of 37 interventions were discussed and 23 implemented in the time frame. Innovative solutions were implemented and teams were empowered by the potential they experienced. 3. An exploration of childhood nutrition and wellness in a subdistrict by patient inclusivity in QI using experience based codesign (EBCD) with mothers/caregivers of malnourished children . Following the steps of EBCD, staff and patients exposed to health services regarding ill children, were interviewed, feedback was given of the findings separately and then in a combined meeting and co-design teams were created to work with the prioritised quality improvement interventions. Touch points in the system were examined through emotional mapping, video interviews and observations. Within the 10 month period of the project, 38 interventions were identified and 25 accepted and implemented at different levels. Conclusion The methodologies were chosen to fit with the qualitative aspect of the research. There were concrete appropriate improvement outcomes due to the engagement of service users in both the primary care clinics serving chronically ill patients and the paediatric system in one subdistrict eg the flow of patients improved, logistical improvements like direct admissions for very ill children, school and library opportunities for admitted ill children etc occurred. Subjective gains like the acknowledgement of their power role by patients and a flattening of the healthcare worker hierarchy were also experienced in the research. Other findings were that unexpected roleplayers were identified, the timeframe of such QI cycles needs to be considered especially regarding the resilience of patients and resources were not an importatn limitation. However some modifications would have to be considered to make these research approaches common practice. The particular research methodologies have not been published in a South African context before and have also not been used for paediatric or integrated chronic illness research and therefore contribute both content and process information to health systems research in South Africa.MT201

Looking for "The Equalizer" in antenatal care : developing and evaluating language-supported group antenatal care in Sweden

Group antenatal care (gANC) is an antenatal care (ANC) model that aims to empower women and has demonstrated potential to improve outcomes for groups of women with poorer reproductive health outcomes. The overall aim of this thesis was to develop and test the acceptability and impact of language-supported gANC for Somali-born women in Sweden. The purpose of the intervention was to improve experiences of antenatal care, emotional well-being, knowledge about childbearing and the Swedish healthcare system, and ultimately, pregnancy outcomes. Experiences of standard ANC were explored in focus group discussions with parents and midwives (Study I). Challenges and barriers in standard antenatal were described, both related to the encounters between midwives and parents-to-be, and organizational challenges. Utilising data from Study I, “language-supported group antenatal care” was developed and implemented in one clinic for 18 months. The intervention was evaluated, and women’s care experiences and emotional wellbeing were compared with those of women offered standard care (historical controls) and those subsequently offered gANC (intervention). Data were collected by means of questionnaires at baseline, in late pregnancy and at 6–8 weeks postpartum (Study II). The development, implementation, and feasibility of the intervention was assessed through a process evaluation using mixed data sources (observations, interviews, questionnaires, etc.) (Study III). In study II, no differences between the intervention group and the control group on the primary outcome of women’s overall rating of antenatal care were found. The reduction in mean EPDS score was greater in the intervention group when adjusting for differences at baseline (mean difference –1.89; CI 95% –3.73 to –0.07). Women in gANC were happier with received pregnancy and birth information; e.g., in the case of caesarean sections, where 94.9% believed the information was sufficient compared to 17.5% in standard care (p <0.001) in late pregnancy. In study III, women in language-supported gANC thought it was a positive experience as a complement to individual care, but the intervention was not successful at involving partners in ANC. In gANC, the midwives and women got to know each other better. The main mechanism of impact was more comprehensive care. The position of women was strengthened in the groups, and the way midwives expanded their understanding of the women, and their narratives, was promising. This evaluation suggests potential for language-supported gANC to improve information provision and knowledge acquisition for Somali–Swedish women during pregnancy (with residence in Sweden ˂10 years). Language-supported gANC is feasible and relevant if there is an adequate number of pregnant migrant or minority women in an uptake area who share a common language. To be feasible in other settings, gANC requires adaptations to local context. Reflection is called for when forming groups based on ethnicity or language, to avoid potential unintended consequences such as reinforcing stereotypes by grouping people according to country of birth or reducing privacy for individual women. The “othering” of women in risk groups should be avoided. There may also be a trade-off in gANC between peer-to-peer support and other important aspects such as the inclusion of partners and integration/inclusion in regular birth preparation and parenting activities. Person-centring seemed to be enhanced with gANC in this study with Somali–Swedish women. ANC interventions including gANC that target inequalities between migrants and non-migrants should adapt a culturally sensitive person-centred approach, as a means of providing individually tailored high quality care that counteracts stereotypes and biases

The Organizational Barriers, Facilitators and Strategies related to the implementation of the Baby Friendly Hospital Initiative (BFHI): A study in selected Palestinian hospitals.

Background: The Baby-Friendly Hospital Initiative (BFHI) aims to promote and support breastfeeding. Globally, around 20,000 facilities have been designated BabyFriendly. In Palestine, only 6 hospitals have the ‘Baby Friendly’ designation since 2010. Despite the increasing evidence for the positive impact of BFHI on breastfeeding and health outcomes, few studies have explored the barriers and facilitating factors influencing to the implementation of Baby-Friendly practices that can be used to enhance the implementation of this initiative in different healthcare settings. Study aim and objectives: The aim of this study is to investigate the organizational factors that hindered or facilitated the implementation of the Baby-Friendly Hospital Initiative (BFHI) in two selected Palestinian governmental and private hospitals, to determine the strategies implemented by the participating hospitals to overcome these barriers and to identify points of convergence and divergence between the explored governmental and private hospitals. Methods: Using an interpretive qualitative approach, A purposive sampling technique was used to conduct in-depth, semi-structured interviews with 15 clinical and nonclinical staff members from different professional groups and managerial positions. Data were analyzed using content comparative analysis method. Results: One of the main organizational facilitators found in this study was the endorsement of a well-coordinated implementation strategy characterized by autocratic BFHI adoption and enforcement, strong administrative support, the presence of BFHIor quality coordinator as well as the financial and technical support by external partners. The designing of mandatory breastfeeding education for all levels of relevant professional groups was found to be also necessary to improve breastfeeding knowledge, attitudes, and practices among staff responsible for the implementation of BFHI tasks. The most frequently reported organizational barriers to implementing the initiative were inadequate staffing especially in the governmental hospital limiting the staff ability to implement BFHI related tasks and provide breastfeeding support. Another commonly reported challenge was hospital structures or routines that interfere with maternal-infant attachment and breastfeeding practices and lack of comprehensive auditing and monitoring tools in both hospitals. Conclusion: findings have indicated that the success of BFHI is achieved by addressing the integrated sociopolitical, organizational and individual factors. The organizational barriers and facilitating factors determined by this study provides a comprehensive model tailored to the Palestinian context which can be adopted to utilize the most effective strategies for a sustainable implementation of the BFHI in different health facilities and consequently the attainment of ‘Baby Friendly’ designation

J Biomed Inform

Responding to public health emergencies requires rapid and accurate assessment of workforce availability under adverse and changing circumstances. However, public health information systems to support resource management during both routine and emergency operations are currently lacking. We applied scenario-based design as an approach to engage public health practitioners in the creation and validation of an information design to support routine and emergency public health activities.|Using semi-structured interviews we identified the information needs and activities of senior public health managers of a large municipal health department during routine and emergency operations.|Interview analysis identified 25 information needs for public health operations management. The identified information needs were used in conjunction with scenario-based design to create 25 scenarios of use and a public health manager persona. Scenarios of use and persona were validated and modified based on follow-up surveys with study participants. Scenarios were used to test and gain feedback on a pilot information system.|The method of scenario-based design was applied to represent the resource management needs of senior-level public health managers under routine and disaster settings. Scenario-based design can be a useful tool for engaging public health practitioners in the design process and to validate an information system design.P01 TP000297/TP/OPHPR CDC HHS/United StatesT15LM007442-08/LM/NLM NIH HHS/United StatesT15 LM007442/LM/NLM NIH HHS/United StatesT15 LM007442-08/LM/NLM NIH HHS/United StatesP01HK000027/HK/PHITPO CDC HHS/United StatesP01 HK000027/HK/PHITPO CDC HHS/United States5P01TP000297/TP/OPHPR CDC HHS/United States2012-12-01T00:00:00Z21807120PMC32269208873vault:728

Greening healthcare: systematic implementation of environmental programmes in a university teaching hospital

peer-reviewedThe provision of healthcare creates significant environmental impacts, and their mitigation is being attempted in a variety of ways which vary from nation to nation in line with differing policy priorities and resource availability. The environmental performance of hospitals has been enhanced through, for example, green building, waste and energy management, and product design. However, unpredictable occupant behaviour, new research outcomes and evolving best practice requires healthcare to react and respond in an ever challenging and changing environment, and clearly there is no one set of actions appropriate in all jurisdictions. Many authors have pointed up negative environmental impacts caused by healthcare, but these studies have focused on particular aspects of mitigation in isolation, and are for this reason not optimal. Here it is argued that tackling impact mitigation through a whole system approach is likely to be more effective. To illustrate what this approach might entail in practice, an evaluation of a systematic implementation of impact mitigation in Ireland's largest teaching hospital, Cork University Hospital is presented. This approach brings together voluntary initiatives in particular those emanating from governmental and non-governmental organisations, peer supports and the adaptation of programmes designed originally for environmental education purposes. Specific measures and initiatives are described, and analysis of results and planned future actions provides a basis for evaluation of successes achieved in achieving mitigation objectives. A crucial attribute of this approach is that it retains its flexibility and connectivity through time, thereby ensuring continual responsiveness to evolving regulation and best practice in green healthcare. It is demonstrated that implementation in Cork resulted both in mitigation of existing impacts, but also a commitment to continual improvement. For such a systems approach to be widely adopted, the healthcare sector needs both leadership from regulators and stakeholders, and strong supports. In Cork it was found that environmental education programmes, especially action and reward based programmes, as utilised by the campus's academic affiliates in particular University College Cork, were especially effective as a framework to address sustainability challenges and should be developed further. However, within healthcare implementation of environmental initiatives must prioritise patient safety. This approach has now been adopted for delivery across the health services sector in Ireland. (C) 2016 Elsevier Ltd. All rights reserved.ACCEPTEDpeer-reviewe