Effectiveness of measures to preserve labour and childbirth companionship at the times of COVID-19 outbreak

Introduction: Although childbirth services were accessible after COVID-19 outbreak, the measures taken by the Italian Government for contagion containment required some restrictions on the presence of trusted persons for mothers, forcing them to isolation during hospitalization. To preserve companionship, the Regional Health Authority of Tuscany issued a resolution providing partners with the possibility to be present during labour and childbirth for non-asymptomatic women. Objectives: In this study, we: 1) analyse the impact of pandemic on companionship in terms of significant reduction of the possibility for women to be accompanied by a trusted person during labour and childbirth; and 2) ascertain if the regional resolution issued was effective in containing the reduction of companionship. Methods: We performed an interrupted time series analysis to measure the variation of the possibility for women to be accompanied by a trusted person during labour and childbirth, in response to formalization of lock-down due to COVID-19 outbreak and the introduction of the regional resolution aimed at contrasting negative effects on companionship. Results and conclusions: The ITS analysis showed that there was a significant decrease in the women-reported experience of companionship in the month of the formalization of lock-down, namely March 2020, followed by a slight increase in the upcoming months. A trend reversal was observed after May 2020, when the regional resolution was fully operational

A m-health intervention in the maternal care pathway: protocol for the impact evaluation of hAPPyMamma (Preprint)

Background: M-health has a great potentiality in both improving quality and efficiency of care, and in increasing health literacy and empowerment of patients-users. There are several studies related to the introduction on m-health tools for supporting pregnancy and the post-natal period, with promising but not still rigorously evaluated impacts. This article contributes to the literature, by presenting an m-health intervention (the mobile app called “hAPPyMamma”) applied in the maternal and child care of a high-income country (in a pilot area of Tuscany Region, Italy) and the methods adopted for evaluating its impact. Objective: The final aim of the introduction of this m-health app in the maternal care pathway is to promote the health of pregnant women and of their children and to improve their experience of care. Methods: This study is based on a quasi-experimental design that compares two groups: women who use the app (intervention group) and women who do not use the app (control group). The data concerning the measures of the maternal health literacy and the empowerment are collected prospectively in order to be able to perform a difference in difference analysis. In the post-partum period also data on women’s experience in the maternal care pathway are collected from both groups and data on the experience of the hAPPyMamma use are collected only within the intervention group. The organisational impact is evaluated through a quantitative and qualitative survey addressing professionals and managers of the maternal care pathway involved in the intervention. Results: The recruitment of the two samples was carried out with the same procedure in 2017, and was subsequent: first, the control group, and after some months, the intervention group. 177 women were enrolled in the control group; out of them, 170 answered to the first web questionnaire and 114 to second one. 150 women were enrolled in the intervention group; out of them, 100 women answered the first web questionnaire and 90 the second one. Data collection was completed in April 2018. Data analysis is underway. Conclusions: This study evaluates the implementation of the m-health intervention hAPPyMamma and describes its impact at individual and organisational level, in terms of the improvement of maternal health literacy, the access to and the utilisation of healthcare services during the maternal care pathway. This study contributes to define the potential role of this m-health tool in maternal care pathway in Tuscany Region and consequently in the Italian context, and the possible extension of its implementation

Is the co-location of GPs in primary care centres associated with a higher patient satisfaction? Evidence from a population survey in Italy

Background: Several countries have co-located General Practitioners (GPs) in Primary Care Centres (PCCs) with other health and social care professionals in order to improve integrated care. It is not clear whether the co-location of a multidisciplinary team actually facilitates a positive patient experience concerning GP care. The aim of this study was to verify whether the co-location of GPs in PCCs is associated positively with patient satisfaction with their GP when patients have experience of a multidisciplinary team. We also investigated whether patients who frequently use health services, due to their complex needs, benefitted the most from the co-location of a multidisciplinary team. Methods: The study used data from a population survey carried out in Tuscany (central Italy) at the beginning of 2015 to evaluate the patients’ experience and satisfaction with their GPs. Multilevel linear regression models were implemented to verify the relationship between patient satisfaction and co-location. This key explanatory variable was measured by considering both the list of GPs working in PCCs and the answers of surveyed patients who had experienced the co-location of their GP in a multidisciplinary team. We also explored the effect modification on patient satisfaction due to the use of hospitalisation, access to emergency departments and visits with specialists, by performing the multilevel modelling on two strata of patient data: frequent and non-frequent health service users. Results: A sample of 2025 GP patients were included in the study, 757 of which were patients of GPs working in a PCC. Patient satisfaction with their GP was generally positive. Results showed that having a GP working within a PCC and the experience of the co-located multidisciplinary team were associated with a higher satisfaction (p < 0.01). For non-frequent users of health services on the other hand, the co-location of multidisciplinary team in PCCs was not significantly associated with patient satisfaction, whereas for frequent users, the strength of relationships identified in the overall model increased (p < 0.01). Conclusion: The co-location of GPs with other professionals and their joint working as experienced in PCCs seems to represent a greater benefit for patients, especially for those with complex needs who use primary care, hospitals, emergency care and specialized care frequently

Co-location of multi-disciplinary professionals within Primary Care Centres in Italy: how do they collaborate? An insight on three cases studies from Tuscany Region through Social Network Analysis

Introduction: Tuscany is one of the few Italian Regions implementing extensively the organisational model of Primary Care Centres (PCCs), based on the co-location of General Practitioners within the same structure with nurses, specialists, social workers and administrative staff and other primary and secondary care services. Although co-location of professionals is considered a key factor for integrated care, it is not sufficient per se to ensure inter-professional collaboration. The aim of the study was to analyse how the professional and clinical integration, in particular the collaboration between professionals of different disciplines, is characterised within PCCs. Methods: Three cases studies of PCCs in Tuscany Region were carried out. Data collection was made through a web survey involving 107 professionals. Social Network Analysis (SNA) was applied. The analysis included visual representation of the networks diagrams, analysis of the network structure, calculation of key network measures and possible associations among them. Results: The response rate differs among the three PCCs and it gives indirectly a proxy measure of the different level of professional involvement in PCC activities. The sharing of electronic data involves the overall networks, but it is mainly functioning among professionals with the same profile and among professionals working within the same service. There are different extents of clinical integration among all professionals. In all PCCs the core nodes of the clinical integration are GPs and nurses, while specialists and social workers are differently involved in the patient care management. Discussion: This study highlights some potentialities and limits of the actual inter-professional collaboration in PCCs. Functional integration, based on sharing electronic patient data, is quite spread although it is more clustered by different disciplines and services. Clinical integration is quite strong between GPs and nurses. The involvement of social workers in patient care pathway should be improved. Sometimes specialists remain as a separate subgroup within the general network of professionals, both as informal relationships and professional relationships. Conclusion: This study gives an innovative perspective on the inter-professional integration within PCCs and provide suggestions supporting decision makers and health services managers to improve professional integration. Lesson learned: The success in implementing the organisational model of PCCs for a better quality of care will depend significantly on their real capacity to promote inter-professional collaboration among the professionals working in these structures. Formalisation of multidisciplinary teams, with defined role and responsibilities, inter-professional and team building training, strengthening of a common information system among professionals may contribute to improve integration in PCCs. Limitations: The non-respondents might have conditioned an under-representation of existing relationships among professionals working in the structure analysed. Since data were collected through questionnaire, some professionals could not have answered exhaustively because of confidentiality reasons, although the closed-ended question format reduce greatly the risk of recall bias. Suggestions for future research: SNA could be applied also in investigating the characteristics of singles nodes within the network (in terms of their position and relationships with the other nodes) and to correlate these measures with the individual perceptions of the PCCs results

Evaluating Healthcare Performance in Low- and Middle-Income Countries: A Pilot Study on Selected Settings in Ethiopia, Tanzania, and Uganda

The literature reports some experiences regarding the design of integrated healthcare Performance Evaluation Systems (PES) applied in Low- and Middle-income Countries (LMIC). This study describes the design of an integrated and bottom-up PES aimed at evaluating healthcare services delivery in rural settings. The analysis involved four hospitals and their relative health districts in Ethiopia, Tanzania, and Uganda. The evaluation process was undertaken for those indicators that could be evaluated using the same reference standard. The evaluation scores were determined through the international standards identified in the literature or through benchmarking assessment. Both administrative and health data were extracted from the hospitals’ registers and District Health Information Systems (DHIS) from 2017 to 2020. We defined 128 indicators: 88 were calculated at the hospital level and 40 at the health district level. The evaluation process was undertaken for 48 indicators. The evaluated indicators are represented using effective graphical tools. In settings characterised by multiple healthcare providers, this framework may contribute to achieving good governance through performance evaluation, benchmarking, and accountability. It may promote evidence-based decision-making in the planning and allocation of resources, thus ultimately fostering quality improvement processes and practices, both at the hospital and health district level

Pregnancy vaccination predictive factors and uptake profiles among Italian women: A cross-sectional survey study on a large population

Objectives: To assess influenza and Tdap (tetanus, diphtheria, pertussis) vaccine coverage during pregnancy, explore key socioeconomic and maternity pathway-related predictors of vaccination, and detect specific patterns of vaccination uptake. Methods: The authors cross-sectionally analyzed self-reported data obtained from the systematic survey on the maternity pathways of Tuscany. They selected all pregnant women that completed from March 2019 to June 2022 the third-trimester questionnaire (n = 25 160), which included two dichotomous items on influenza and Tdap vaccination, as well as socioeconomic and pathway-related questions. Multilevel logistic models were performed to assess vaccination predictors and cluster analysis to identify vaccination patterns. Results: Vaccination coverage was higher for pertussis (56.5%) than for influenza (18.9%). The main predictors of vaccination were high socioeconomic status, attending private gynecologists, and receiving vaccine information. Three clusters were identified: cluster 1 included women receiving both Tdap and influenza vaccines; cluster 2 included women receiving no vaccinations; and cluster 3 included women receiving only the pertussis vaccine. Although women from cluster 3 were of middle to low education status, vaccine information was the main adherence determinant also in this group. Conclusions: Health workers and policymakers should focus on groups of pregnant women less prone to vaccination to promote vaccination information and encourage wider uptake and coverage

The COVID-19 emergency as an opportunity to co-produce an innovative approach to health services provision: the women's antenatal classes move on the web

The COVID-19 pandemic has strongly affected healthcare organizations, leading to the need for reorganizing also maternal care services during pregnancy. The Regional Health Authorities in Tuscany (Italy) promoted the creation of online antenatal classes (ACs). This study illustrates the innovative approach to deliver ACs online and discusses how the collaborative approach in co-producing this innovative solution co-creates value in healthcare. The action research design was based, on one hand, on the indirect involvement of users by analyzing qualitative data collected through a continuous survey to pregnant women and, on the other one, on the direct involvement of managers and health professionals in meetings and workshops. The authors encompassed all necessary changes in organizational practices and facilitated the collaborative process implementation and analysis. The main findings are that moving ACs online has been a relevant choice, since the need of pregnant women to share information and receive emotional support increased in times of crisis. Additionally, in the perspective of health professionals, the new online ACs model emerged as a valuable solution not only for the contingent situation, but also in a long-term perspective to reach more women during pregnancy and to early support them throughout the maternal care pathway. This study shows that the collaborative approach to co-innovate healthcare services provision, such as with ACs online, facilitates the creation of, long-lasting, and integrated solutions in healthcare, to be used also after pandemic period. Finally, despite this action-research is context-specific, the findings presented in this paper may help other healthcare organizations innovate their own strategies in ACs’ provision

Quality of life, vulnerability and resilience: a qualitative study of the tsunami impact on the affected population of Sri Lanka

AIM: This qualitative study is aimed at analysing the impact of the 2004 tsunami on the Quality of Life of the Sri Lankan population. It focused on the factors that have contributed to an increase in the people's susceptibility to the impact of hazards - their vulnerability - as well as of the natural ability to cope of the populations affected - their resilience. METHODOLOGY: The study is based on the conduction of 10 Focus Group discussions and 18 In-depth Interviews, then analysed through a qualitative analysis software. RESULTS AND CONCLUSIONS: The analysis shows that each factor involved in the interplay among the different processes that produced the changes in the affected people's quality of life is at the same time a damaged asset, a vulnerability factor and a resource to draw upon for coping. The complexity of this situation opens further speculation as to how disasters and relief interventions influence relationships and dynamics in society. This should thus be further investigated, together with the effects of individual and group trauma on society