A mixed method multi-Country assessment of barriers to implementing pediatric inpatient care guidelines

Introduction: Accelerating progress in reducing child deaths is needed in order to achieve the Sustainable Development Goal child mortality target. This will require a focus on vulnerable children-including young children, those who are undernourished or with acute illnesses requiring hospitalization. Improving adherence to inpatient guidelines may be an important strategy to reduce child mortality, including among the most vulnerable. The aim of our assessment of nine sub-Saharan African and South Asian hospitals was to determine adherence to pediatric inpatient care recommendations, in addition to capacity for and barriers to implementation of guideline-adherent care prior to commencing the Childhood Acute Illness and Nutrition (CHAIN) Cohort study. The CHAIN Cohort study aims to identify modifiable risk factors for poor inpatient and post discharge outcomes above and beyond implementation of guidelines.Methods: Hospital infrastructure, staffing, durable equipment, and consumable supplies such as medicines and laboratory reagents, were evaluated through observation and key informant interviews. Inpatient medical records of 2-23 month old children were assessed for adherence to national and international guidelines. The records of children with severe acute malnutrition (SAM) were oversampled to reflect the CHAIN study population. Seven core adherence indicators were examined: oximetry and oxygen therapy, fluids, anemia diagnosis and transfusion, antibiotics, malaria testing and antimalarials, nutritional assessment and management, and HIV testing.Results: All sites had facilities and equipment necessary to implement care consistent with World Health Organization and national guidelines. However, stockouts of essential medicines and laboratory reagents were reported to be common at some sites, even though they were mostly present during the assessment visits. Doctor and nurse to patient ratios varied widely. We reviewed the notes of 261 children with admission diagnoses of sepsis (17), malaria (47), pneumonia (70), diarrhea (106), and SAM (119); 115 had multiple diagnoses. Adherence to oxygen therapy, antimalarial, and malnutrition refeeding guidelines was \u3e75%. Appropriate antimicrobials were prescribed for 75% of antibiotic-indicative conditions. However, 20/23 (87%) diarrhea and 20/27 (74%) malaria cases without a documented indication were prescribed antibiotics. Only 23/122 (19%) with hemoglobin levels meeting anemia criteria had recorded anemia diagnoses. HIV test results were infrequently documented even at hospitals with universal screening policies (66/173, 38%). Informants at all sites attributed inconsistent guideline implementation to inadequate staffing.Conclusion: Assessed hospitals had the infrastructure and equipment to implement guideline-consistent care. While fluids, appropriate antimalarials and antibiotics, and malnutrition refeeding adherence was comparable to published estimates from low- and high-resource settings, there were inconsistencies in implementation of some other recommendations. Stockouts of essential therapeutics and laboratory reagents were a noted barrier, but facility staff perceived inadequate human resources as the primary constraint to consistent guideline implementation

Familial Aggregation of High Tumor Necrosis Factor Alpha Levels in Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) patients frequently have high circulating tumor necrosis factor alpha (TNF-α) levels. We explored circulating TNF-α levels in SLE families to determine whether high levels of TNF-α were clustered in a heritable pattern. We measured TNF-α in 242 SLE patients, 361 unaffected family members, 23 unaffected spouses of SLE patients, and 62 unrelated healthy controls. Familial correlations and relative recurrence risk rates for the high TNF-α trait were assessed. SLE-affected individuals had the highest TNF-α levels, and TNF-α was significantly higher in unaffected first degree relatives than healthy unrelated subjects (P=0.0025). No Mendelian patterns were observed, but 28.4% of unaffected first degree relatives of SLE patients had high TNF-α levels, resulting in a first degree relative recurrence risk of 4.48 (P=2.9×10-5). Interestingly, the median TNF-α value in spouses was similar to that of the first degree relatives. Concordance of the TNF-α trait (high versus low) in SLE patients and their spouses was strikingly high at 78.2%. These data support a role for TNF-α in SLE pathogenesis, and TNF-α levels may relate with heritable factors. The high degree of concordance in SLE patients and their spouses suggests that environmental factors may also play a role in the observed familial aggregation

Pivoting Youth HIV Service During the COVID-19 Pandemic: Evaluation of Phone Delivery of an Adolescent Transition Package in Kenya

Thesis (Ph.D.)--University of Washington, 2023The global burden of HIV attributable to young people aged 10 – 24 years living with HIV is significant and approximates 2 million youth. The reality of HIV along with the vulnerability associated with being a teenager makes this population one worth paying close attention to given poor HIV outcomes associated with youth living with HIV (YLH). Maintaining engagement in care is critical, especially for older youth aged 15 – 24 years who experience worse HIV-related outcomes than adults or younger adolescents. The risk of loss-to-follow-up is high among YLH transitioning from pediatric to adult HIV clinics. Among youth, mHealth technology has demonstrated the ability to bridge gaps in utilizing health services that are common in this age group, including improving engagement and retaining in care. During the COVID-19 pandemic mHealth was invaluable for HIV clinics as it supported remote access to health services. The Adolescent Transition to Adult Care for HIV-infected Adolescents in Kenya (ATTACH) study which tested an Adolescent Transition Package (ATP) to support YLH transition pivoted from in-person delivery to phone delivery of the intervention. We sought to assess implementation of the ATP using phones to identify best practices for use beyond the pandemic. The first study used qualitative data from providers who work with YLH at public HIV clinics in Kenya to identify barriers and facilitators associated with phone delivery of the ATP intervention. We gathered data enumerating the number of phone calls and the success of each call as far as reaching youth and discussing a chapter of the ATP was concerned. The use of mobile phones was high in the early stages of the pandemic but quickly declined once movement restrictions were lifted. Initially, the providers were less successful at reaching youth until after restrictions were lifted. Using the Consolidated Framework for Implementation Research we found that salient factors influencing acceptability, feasibility and reach were related to the technical simplicity of phone calls, relative convenience, and efficiency of using phones (intervention characteristics), and to inner setting characteristics such as the presence of collaborative teams, individual and collective efficacy to complete tasks, availability of information and resources, and compatibility with the providers’ existing responsibilities. Determinants related to patient needs and resources and community, specifically low phone ownership among youth, and the youths’ relationships, were important. The second study applied the Framework for Reporting Adaptations - Implementation Strategies (FRAME-IS) to characterize provider-led adaptations to mobile phone delivery of the identified from qualitative data collected during Continuous Quality Improvement meetings. Adaptation of phone delivery was a feasible and effective way of addressing challenges with continuity of care for YLH during the COVID-19 pandemic. Most adaptations were derived from changes to the strategy’s context and majority were introduced to increase the feasibility of phone delivery. Most adaptations were either incorporated into routine workflows (47%) or tested again (47%). Adaptations were primarily context adaptions. We found that FRAME-IS was apt for describing adaptations. We propose other uses of FRAME-IS for providers engaged in quality improvement work. The third study used a convergent mixed methods approach to compare youth satisfaction with phone delivery versus in-person delivery of the ATP. We identified higher satisfaction with both options; however, the preference was for receiving in-person delivery compared to phone call delivery of the ATP. Privacy and confidentiality, patient-provider relationship and connection, convenience, and averted time and financial costs were notable drivers of YLH’s perspectives that may be important to consider when designing service delivery strategies for YLH. This dissertation contributes to much needed implementation science research on mHealth in relation to the care of youth living with HIV and underscores factors for consideration when implementing mHealth for this target population. As new efforts emerge to address poor HIV outcomes among YLH, providers and policymakers will require a nuanced understanding of implementation barriers and facilitators, and adaptations. This work highlighted the importance of evaluating YLH experiences with health services to better match delivery strategies to their preferences and needs

Assessing the Suitability of a Mobile Phone-Based Case Management System for Children in Adversity in Battambang, Cambodia

<p>Abstract</p><p>There are over 250 million children in adversity (CIA) globally; however, insufficient information on prevalence of CIA and their daily needs limits case management of this group by social welfare systems. Recently, mobile technology-based (mHealth) systems have been used successfully to extend health services and information to clients in hard-to-reach, under resourced areas. This study aimed to determine the suitability of mHealth systems for improving case management of CIA in Battambang Province, Cambodia. </p><p>Methods used included focus group discussions (FGDs), in depth interview and direct observation with government and NGO social workers, their supervisors and street-based CIA (10-17 years). Data on daily workflows, roles, responsibilities and case management activities of social workers were documented. Mobile phone ownership, use and attitudes among social workers were used to assess suitability of an mHealth tool in the Cambodian context. Daily life experiences and case management needs of CIA were documented. </p><p>Our data suggests that routine case management of CIA is limited by low capacity of social workers, logistical constraints, a burdensome paper-based data collection system, scanty resources and poor supportive supervision. All social workers participating in the study owned and used mobile phones, and enthusiasm for further incorporation of these devices into daily work activities was high. Street children came from different situations of adversity, were under-served and had diverse case management needs such as referral to vocational programs, early intervention to prevent violence in the home and continuous follow-up. </p><p>An mHealth system could be developed to overcome constraints in case management of CIA by streamlining social worker workflows, facilitating timely data collection, and enabling continuous training of social workers. Such a system, implemented in conjunction with other initiatives to strengthen the social welfare system, could promote better case management for CIA in Cambodia, and globally.</p>Thesi

Characterizing provider-led adaptations to mobile phone delivery of the Adolescent Transition Package (ATP) in Kenya using the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS): a mixed methods approach

Abstract Background The COVID-19 pandemic resulted in disruptions to routine HIV services for youth living with HIV (YLH), provoking rapid adaptation to mitigate interruptions in care. The Adolescent Transition to Adult Care for HIV-infected adolescents (ATTACH) study (NCT03574129) was a hybrid I cluster randomized trial testing the effectiveness of a healthcare worker (HCW)-delivered disclosure and transition intervention — the Adolescent Transition Package (ATP). During the pandemic, HCWs leveraged phone delivery of the ATP and were supported to make adaptations. We characterized real-time, provider-driven adaptations made to support phone delivery of the ATP. Methods We conducted continuous quality improvement (CQI) meetings with HCWs involved in phone delivery of the ATP at 10 intervention sites. CQI meetings used plan-do-study-act (PDSA) cycles and were audio-recorded. Adaptations were coded by two-independent coders using the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS). Adaptation testing outcomes (adopt, retest, or abandon) and provider experience implementing the adaptations were also recorded. We summarized adaptation characteristics, provider experience, and outcomes. Results We identified 72 adaptations, 32 were unique. Overall, adaptations included modification to context (53%, n = 38), content (49%, n = 35), and evaluation processes (13%, n = 9). Context adaptations primarily featured changes to personnel, format, and setting, while content and evaluation adaptations were frequently achieved by simple additions, repetition, and tailoring/refining of the phone delivery strategy. Nine adaptations involved abandoning, then returning to phone delivery. HCWs sought to increase reach, improve fidelity, and intervention fit within their context. Most adaptations (96%, n = 69) were perceived to increase the feasibility of phone delivery when compared to before the changes were introduced, and HCWs felt 83% (n = 60) of adaptations made phone delivery easier. Most adaptations were either incorporated into routine workflows (47%) or tested again (47%). Conclusion Adaptation of phone delivery was a feasible and effective way of addressing challenges with continuity of care for YLH during the COVID-19 pandemic. Adaptations were primarily context adaptions. While FRAME-IS was apt for characterizing adaptations, more use cases are needed to explore the range of its utility. Trial registration Trial registered on ClinicalTrial.gov as NCT03574129

Pediatric Inpatient Antibiotic Prescription Practices in the Chain Network Hospitals at Baseline

This analysis describes adherence to antibiotic guidelines during the first 48 hours of admission. Adherence was defined as a regimen consistent with institutional, national, or international recommendations.Antimicrobial resistance (AMR) is a growing global concern. Antibiotic stewardship is being promoted to reduce AMR. However, few studies have documented inpatient antibiotic prescription practices in low resource settings. We audited the 240 clinical notes of 2-23 month-old inpatient children in Bangladesh (2), Kenya (3), Malawi (1), Pakistan (1) and Uganda (1) as part of a baseline assessment in a study to identify risk factors for mortality in acutely ill inpatients, particularly in undernourished children. This analysis describes adherence to antibiotic guidelines during the first 48 hours of admission. Adherence was defined as a regimen consistent with institutional, national, or international recommendations. The cases reviewed included diagnoses of diarrhea (n:107), severe acute malnutrition (n:101), pneumonia (n:76), malaria (n:35), sepsis (n:25), meningitis (n:12), and shock (n:8). Antibiotics were prescribed to 98% with at least one documented indication for antibiotics (n:173); 80% of these were consistent with recommended regimens. Antibiotics were prescribed in 93% of admitted diarrhea cases, 85% of whom had a comorbidity warranting antimicrobials (n:85) or dysentery (n:1). Among children with malaria noted as a diagnosis and without a documented indication for antibiotics (n:22), those who did not receive a malaria test (n:6) were all prescribed antibiotics. In comparison, 63% of those with a documented positive malaria test (n:16) were prescribed antibiotics without indication. Among those with diarrhea (n:15) and malaria (n:16) without a documented indication for antibiotics, 58% were prescribed an antimicrobial regimen consistent with treatment for a severe bacterial infection. Antibiotics were almost universally prescribed when indicated and adherence to a recommend regimen was comparable to other studie

Demand creation for HIV testing services: A systematic review and meta-analysis.

BackgroundHIV testing services (HTS) are the first steps in reaching the UNAIDS 95-95-95 goals to achieve and maintain low HIV incidence. Evaluating the effectiveness of different demand creation interventions to increase uptake of efficient and effective HTS is useful to prioritize limited programmatic resources. This review was undertaken to inform World Health Organization (WHO) 2019 HIV testing guidelines and assessed the research question, "Which demand creation strategies are effective for enhancing uptake of HTS?" focused on populations globally.Methods and findingsThe following electronic databases were searched through September 28, 2021: PubMed, PsycInfo, Cochrane CENTRAL, CINAHL Complete, Web of Science Core Collection, EMBASE, and Global Health Database; we searched IAS and AIDS conferences. We systematically searched for randomized controlled trials (RCTs) that compared any demand creation intervention (incentives, mobilization, counseling, tailoring, and digital interventions) to either a control or other demand creation intervention and reported HTS uptake. We pooled trials to evaluate categories of demand creation interventions using random-effects models for meta-analysis and assessed study quality with Cochrane's risk of bias 1 tool. This study was funded by the WHO and registered in Prospero with ID CRD42022296947. We screened 10,583 records and 507 conference abstracts, reviewed 952 full texts, and included 124 RCTs for data extraction. The majority of studies were from the African (N = 53) and Americas (N = 54) regions. We found that mobilization (relative risk [RR]: 2.01, 95% confidence interval [CI]: [1.30, 3.09], p ConclusionsMobilization, couple- and motivation-oriented counseling, peer-led interventions, conditional fixed value incentives, and SMS are high-impact demand creation interventions and should be prioritized for programmatic consideration. Reduced duration counseling and video-based interventions are an efficient and effective alternative to address staffing shortages. Investment in demand creation activities should prioritize those with undiagnosed HIV or ongoing HIV exposure. Selection of demand creation interventions must consider risks and benefits, context-specific factors, feasibility and sustainability, country ownership, and universal health coverage across disease areas

A mixed method multi-country assessment of barriers to implementing pediatric inpatient care guidelines.

INTRODUCTION:Accelerating progress in reducing child deaths is needed in order to achieve the Sustainable Development Goal child mortality target. This will require a focus on vulnerable children-including young children, those who are undernourished or with acute illnesses requiring hospitalization. Improving adherence to inpatient guidelines may be an important strategy to reduce child mortality, including among the most vulnerable. The aim of our assessment of nine sub-Saharan African and South Asian hospitals was to determine adherence to pediatric inpatient care recommendations, in addition to capacity for and barriers to implementation of guideline-adherent care prior to commencing the Childhood Acute Illness and Nutrition (CHAIN) Cohort study. The CHAIN Cohort study aims to identify modifiable risk factors for poor inpatient and post discharge outcomes above and beyond implementation of guidelines. METHODS:Hospital infrastructure, staffing, durable equipment, and consumable supplies such as medicines and laboratory reagents, were evaluated through observation and key informant interviews. Inpatient medical records of 2-23 month old children were assessed for adherence to national and international guidelines. The records of children with severe acute malnutrition (SAM) were oversampled to reflect the CHAIN study population. Seven core adherence indicators were examined: oximetry and oxygen therapy, fluids, anemia diagnosis and transfusion, antibiotics, malaria testing and antimalarials, nutritional assessment and management, and HIV testing. RESULTS:All sites had facilities and equipment necessary to implement care consistent with World Health Organization and national guidelines. However, stockouts of essential medicines and laboratory reagents were reported to be common at some sites, even though they were mostly present during the assessment visits. Doctor and nurse to patient ratios varied widely. We reviewed the notes of 261 children with admission diagnoses of sepsis (17), malaria (47), pneumonia (70), diarrhea (106), and SAM (119); 115 had multiple diagnoses. Adherence to oxygen therapy, antimalarial, and malnutrition refeeding guidelines was >75%. Appropriate antimicrobials were prescribed for 75% of antibiotic-indicative conditions. However, 20/23 (87%) diarrhea and 20/27 (74%) malaria cases without a documented indication were prescribed antibiotics. Only 23/122 (19%) with hemoglobin levels meeting anemia criteria had recorded anemia diagnoses. HIV test results were infrequently documented even at hospitals with universal screening policies (66/173, 38%). Informants at all sites attributed inconsistent guideline implementation to inadequate staffing. CONCLUSION:Assessed hospitals had the infrastructure and equipment to implement guideline-consistent care. While fluids, appropriate antimalarials and antibiotics, and malnutrition refeeding adherence was comparable to published estimates from low- and high-resource settings, there were inconsistencies in implementation of some other recommendations. Stockouts of essential therapeutics and laboratory reagents were a noted barrier, but facility staff perceived inadequate human resources as the primary constraint to consistent guideline implementation

PRISMA flowchart.

BackgroundHIV testing services (HTS) are the first steps in reaching the UNAIDS 95-95-95 goals to achieve and maintain low HIV incidence. Evaluating the effectiveness of different demand creation interventions to increase uptake of efficient and effective HTS is useful to prioritize limited programmatic resources. This review was undertaken to inform World Health Organization (WHO) 2019 HIV testing guidelines and assessed the research question, “Which demand creation strategies are effective for enhancing uptake of HTS?” focused on populations globally.Methods and findingsThe following electronic databases were searched through September 28, 2021: PubMed, PsycInfo, Cochrane CENTRAL, CINAHL Complete, Web of Science Core Collection, EMBASE, and Global Health Database; we searched IAS and AIDS conferences. We systematically searched for randomized controlled trials (RCTs) that compared any demand creation intervention (incentives, mobilization, counseling, tailoring, and digital interventions) to either a control or other demand creation intervention and reported HTS uptake. We pooled trials to evaluate categories of demand creation interventions using random-effects models for meta-analysis and assessed study quality with Cochrane’s risk of bias 1 tool. This study was funded by the WHO and registered in Prospero with ID CRD42022296947.We screened 10,583 records and 507 conference abstracts, reviewed 952 full texts, and included 124 RCTs for data extraction. The majority of studies were from the African (N = 53) and Americas (N = 54) regions. We found that mobilization (relative risk [RR]: 2.01, 95% confidence interval [CI]: [1.30, 3.09], p p N = 4 RCTs), couple-oriented counseling (RR: 1.98, 95% CI [1.02, 3.86], p p N = 4 RCTs), peer-led interventions (RR: 1.57, 95% CI [1.15, 2.15], p p N = 10 RCTs), motivation-oriented counseling (RR: 1.53, 95% CI [1.07, 2.20], p p N = 4 RCTs), short message service (SMS) (RR: 1.53, 95% CI [1.09, 2.16], p p N = 5 RCTs), and conditional fixed value incentives (RR: 1.52, 95% CI [1.21, 1.91], p p N = 11 RCTs) all significantly and importantly (≥50% relative increase) increased HTS uptake and had medium risk of bias.Lottery-based incentives and audio-based interventions less importantly (25% to 49% increase) but not significantly increased HTS uptake (medium risk of bias). Personal invitation letters and personalized message content significantly but not importantly (ConclusionsMobilization, couple- and motivation-oriented counseling, peer-led interventions, conditional fixed value incentives, and SMS are high-impact demand creation interventions and should be prioritized for programmatic consideration. Reduced duration counseling and video-based interventions are an efficient and effective alternative to address staffing shortages. Investment in demand creation activities should prioritize those with undiagnosed HIV or ongoing HIV exposure. Selection of demand creation interventions must consider risks and benefits, context-specific factors, feasibility and sustainability, country ownership, and universal health coverage across disease areas.</div

(A and B) Risk of bias summary.

Panel (A): Pooled studies. Studies are grouped by the meta-analysis that they contributed to. Panel (B): Not pooled studies. Studies that were not pooled are listed in alphabetical order.</p