COVID-19 healthcare and social-related needs from the perspective of Spanish patients and healthcare providers: a qualitative analysis of responses to open-ended questions

IntroductionIdentifying stakeholders’ needs is crucial to informing decisions and policy development. This study aims to identify healthcare and social-related needs and effective strategies associated with COVID-19 from the first-person perspectives of patients and healthcare providers.MethodsCross-sectional online survey design including qualitative open-ended questions, conducted in primary care and hospital settings across Spain, with 12 out of 19 regions represented. Adults aged 18 years and older, who (a) resided in Spain and had a history of COVID-19 or (b) worked as healthcare providers delivering direct or indirect care for people with COVID-19 in Spanish primary care or hospitals during 2020 were eligible to participate. Recruitment was conducted via social-media networks (Twitter, LinkedIn, and WhatsApp) and communication channels of key organizations including patient and professional associations and groups. A total of 182 people were invited to complete the surveys and 76 people completed the surveys (71% women), of which 33 were home-isolated patients, 14 were hospitalized patients, 16 were primary care professionals, and 13 were hospital care professionals.ResultsA total of 327 needs and 86 effective strategies and positive aspects were identified across surveys and classified into the following overarching themes: (i) Accessibility, (ii) Basic needs, (iii) Clinical care, (iv) Person-and-family centered care, (v) Caring for the healthcare professional, (vi) Protocolization, information, health campaigns, and education, (vii) Resource availability, (viii) and Organizational needs/strategies.DiscussionFindings indicate the Spanish health and social care systems were generally unprepared to combat COVID-19. Implications for research, practice, and policy focus on integrating first-person perspectives as best practice to identify, prioritize and address needs to increase health and social care systems capacity and preparedness, as well as providing well-co-coordinated responses across government, healthcare, and non-government sectors to promote and protect the physical and mental health of all

(Re)defining Healthcare Quality: Metrics, Protocols, and the Restructuring of Care Delivery

Healthcare organizations in the United States are increasingly evaluated by systems that link quality measurement with regulatory and payment approaches. Operationalized through quality measurement, quality is affirmed as the basis for improving healthcare processes, outcomes, and health systems broadly. At the same time, electronic health record (EHR) and other information technology (IT) systems aimed to make care safer and more efficient, have become standard tools in healthcare settings. Galvanized by these technical advancements, quality metrics are considered crucial components of ensuring accountability for improved health outcomes and care equity.This dissertation aims to understand healthcare quality measurement by investigating how systems of quality measurement are implemented in clinical spaces, particularly how they structure care delivery and define quality. This dissertation offers a qualitative study of the organizational and structural elements of quality and quality measurement. I conducted ethnographic observation (15 months) and interviews (n=31) at a 600-bed, acute-care hospital in New York City, which I call Borough Hospital. My analysis utilizes the accounts of healthcare clinicians and administrators, and their experiences navigating care delivery and quality in their hospital. Through this analysis, I investigate the variable meanings of quality, processes of measuring quality, and the conditions under which care is delivered at Borough Hospital. Using the qualitative analytic methods of grounded theory and situational analysis, I deconstruct the ways in which quality and quality measurement are constructed as neutral and inevitable, how care delivery is increasingly protocolized to ensure quality, and the ensuing distancing of quality care away from the bedside. Meeting and complying with quality metrics require specific clinical care protocols and extensive documentation for reporting. These new requirements have changed the roles and responsibilities of frontline clinicians, shifting the organization of labor in the clinic. I argue that measurement-based, clinical protocols that rely on surveillance and abstracted documentation data increasingly standardize processes of quality care and distance care—that is, clinician labor— away from the bedside. The findings of this dissertation suggest a tendency toward protocolization and narrowing definitions of quality, which can be extended into other hospital systems particularly in light of widespread consolidation. I argue that administrative prioritization of quality measurement, and in particular quality metrics, necessitates the protocolization of complex healthcare processes and increasingly relies on data-driven decision-making. Ultimately, I suggest quality care has been (re)defined by measurement-based, clinical protocols, which I call abstracted surveillance protocols, that increasingly standardize and constrain care delivery

Perspectives On Emergency Department-Initiated Buprenorphine Among Clinical Pharmacists

Clinical pharmacists are well positioned to enhance efforts to promote Emergency Department (ED)-initiated buprenorphine to treat opioid use disorder (OUD). Among clinical pharmacists in urban EDs, we sought to characterize barriers and facilitators for ED-initiated buprenorphine to inform future implementation efforts and enhance access to this highly effective OUD treatment. This study was conducted as a part of Project ED Health (CTN-0069, NCT03023930), a multisite effectiveness-implementation study aimed at promoting ED-initiated buprenorphine that was conducted between April 2017 and July 2020. Data collection and analysis were grounded in the Promoting Action on Research Implementation in Health Services (PARIHS) framework to assess perspectives on the relationship between 3 elements: evidence for buprenorphine initiation, the ED context, and facilitation needs to promote ED-initiated buprenorphine. Using content analysis, an iterative coding process was used to identify overlapping themes within these 3 domains. Eight focus groups/interviews were conducted across four geographically disparate EDs with 15 pharmacist participants. Six themes were identified. Themes related to evidence included (1) varied levels of comfort and experience among pharmacists with ED-initiated buprenorphine that increased over time and (2) a perception that patients with OUD have unique challenges that require guidance to optimize ED care. Regarding the context, clinical pharmacists identified: (3) their ability to clarify scope of ED care in the context of unique pharmacology, formulations, and regulations of buprenorphine to ED staff, and that (4) their presence promotes successful program implementation and quality improvement. Participants identified facilitation needs including: (5) training to promote practice change and (6) ways to leverage already existing pharmacy resources outside of the ED. Clinical pharmacists play a unique and critical role in the efforts to promote ED-initiated buprenorphine. We identified 6 themes that can inform pharmacist-specific interventions that could aid in the successful implementation of this practice

Mobile health intervention to increase oral cancer therapy adherence in patients with chronic myeloid leukemia (the REMIND system): clinical feasibility and acceptability assessment

Background: Optimal dosing of oral tyrosine kinase inhibitor therapy is critical to treatment success and survival of patients with chronic myeloid leukemia (CML). Drug intolerance secondary to toxicities and nonadherence are significant factors in treatment failure.Objective: The objective of this study was to develop and pilot-test the clinical feasibility and acceptability of a mobile health system (REMIND) to increase oral drug adherence and patient symptom self-management among people with CML (chronic phase).Methods: A multifaceted intervention was iteratively developed using the intervention development framework by Schofield and Chambers, consisting of defining the patient problem and iteratively refining the intervention. The clinical feasibility and acceptability were examined via patient and intervention nurse interviews, which were audiotaped, transcribed, and deductively content analyzed.Results: The intervention comprised 2 synergistically operating elements: (1) daily medication reminders and routine assessment of side effects with evidence-based self-care advice delivered in real time and (2) question prompt list (QPL) questions and routinely collected individual patient adherence and side effect profile data used to shape nurses’ consultations, which employed motivational interviewing to support adoption of self-management behaviors. A total of 4 consultations and daily alerts and advice were delivered over 10 weeks. In total, 58% (10/17) of patients and 2 nurses participated in the pilot study. Patients reported several benefits of the intervention: help in establishing medication routines, resolution of symptom uncertainty, increased awareness of self-care, and informed decision making. Nurses also endorsed the intervention: it assisted in establishing pill-taking routines and patients developing effective solutions to adherence challenges.Conclusions: The REMIND system with nurse support was usable and acceptable to both patients and nurses. It has the potential to improve adherence and side-effect management and should be further evaluated

Developing integrated guidelines for health care workers in hospital and primary healthcare facilities in response to the COVID-19 pandemic in low- and middle- income countries (LMICs)

COVID-19 has placed an enormous burden on health systems globally. In response to the demands of the pandemic, there has been an urgent need to capacity build healthcare workers (HCWs) to reduce nosocomial transmission, strengthen triage systems, and rapidly identify cases to break chains of transmission in the community. The World Health Organization (WHO) has produced technical guidance documents for patient management, risk communication, infection control, etc. However, the guidance does not address health system challenges or implementation difficulties in resource-constrained settings such as LMICs. Further, while guidance provides valuable information for HCWs it must be complemented with training to ensure protocolization and uptake into practice. This is particularly important in the context of COVID-19, which has been hallmarked by waves of infections, resource scarcity, and growing stigma

Developing integrated guidelines for health care workers in hospital and primary healthcare facilities in response to the COVID-19 pandemic in low-and middle-income countries (LMICs)

COVID-19 has placed an enormous burden on health systems globally. In response to the demands of the pandemic, there has been an urgent need to capacity build HCWs (e.g., nurses, doctors, community health workers, and others) to reduce nosocomial transmission, strengthen triage systems, and rapidly identify cases to break chains of transmission in the community. The World Health Organization (WHO) has produced technical guidance documents for patient management, risk communication, infection control, etc. However, the guidance does not address health system challenges or implementation difficulties in resource-constrained settings such as LMICs. Further, while guidance provides valuable information for HCWs it must be complemented with training to ensure protocolization and uptake into practice. This is particularly important in the context of COVID-19, which has been hallmarked by waves of infections, resource scarcity, and growing stigma

To What Extent are Frontline Statutory Social Workers Employing Their Discretion in the Post- Munro Review World of Child Protection?

In May 2011, Eileen Munro concluded her review of the English child protection system. Within, she identified obstacles which she believed were hindering the realisation of an ‘effective’ and ‘child-centred’ system. This included the ‘risk’ associated with the social worker’s discretionary space, leading managers to restrict, and practitioners to minimise, opportunities for frontline discretion. It was on this basis that Munro called for reform of the system, so that social workers would be better able and motivated to exercise their discretion in the best interests of the individual child. It is also in these terms that the author set out to explore the degree to which social workers are employing their discretion within the contemporary child protection system. This thesis reports on the results of a qualitative mixed methods case study of one local authority’s child protection team. The focus of enquiry pertained to the extent and nature of the discretionary space encountered; whether social workers were willing to employ discretion within different contexts; and the factors that were understood to be impacting upon discretionary space and choice. The research comprised of an iterative design, incorporating focus group, questionnaire, interview, observation and documentary analysis. The main findings were that social workers were experiencing discretionary space in a de jure, de facto and entrepreneurial sense; that practitioners were more likely to choose to exercise their discretion within the managerially endorsed space; and that a series of systemic factors were continuing to impede both the opportunities for, and propensity to choose, discretion. Ultimately, whilst the research provides some evidence in favour of Munro’s image for discretion within the system, the identification of continued barriers leads to the thesis’ conclusion that further reform may be required if child protection social workers are to more consistently employ their discretion in the interests of the individual child

Mapa de la recerca del Campus de Vilanova i la Geltrú

Postprint (author’s final draft

Power, Gender, and Trust in Experiences of Pediatric Emergency Physician Teleconsultation and Maternal Antenatal Anxiety in Pakistan

Background: In Pakistan, innovative strategies for improving access to health care, such as telemedicine (TM) and task shifting, are growing rapidly to address critical gaps in maternal and child health (MCH). Qualitative studies of social and contextual factors can help improve the development or implementation of such interventions. Objectives: This dissertation closely examines constructs of power, gender, and trust in the contexts of two populations: (1) pediatric emergency medicine (PEM) providers in a novel TM program applying synchronous expert teleconsultation to improve quality of care, and (2) pregnant women with experiences of anxiety informing the content of a psychological intervention by non-specialists. Methods: Manuscript one uses the TM Theory of Use framework to thematically analyze 20 in-depth interviews covering experiences or perspectives of doctors, nurses, and TM program administrators, while Manuscript two draws on conversation analysis methods to examine transcripts of 88 PEM teleconsultations. Manuscript three is a secondary analysis applying a women’s empowerment framework to formative research interviews on sources and mitigators of antenatal anxiety in 19 symptomatic women. Data for the qualitative TM program evaluation were collected from October 2019 to January 2020 at Sindh government hospitals, while formative research interviews on antenatal anxiety were conducted between September 2017 and August 2018 at Holy Family Hospital in Rawalpindi. Results: Perceived levels of asymmetric power and mutual trust in TM produced widely divergent and conflicting theories of use among PEM providers, while some gender-based opportunities in TM contributed to emergent social functions beyond its intended aims. Although teleconsultants accounted for a disproportionate share of asking questions and controlling topic, closer examination revealed strategic ambiguity and reciprocity as means of negotiating power and building trust in TM-mediated clinical discourse, particularly by women teleconsultants. For antenatal anxiety, gender norms and women’s disempowerment were key contextual factors contributing to women’s symptoms and limiting pregnancy-related agency and available coping strategies. Conclusion: Efforts to expand access to high quality care for mothers and children must include studies of context, whether the sociotechnical context of TM innovations or the cultural context of psychosocial interventions, to understand associated opportunities, constraints, successes, and failures in improving MCH