Development and testing of a composite index to monitor the continuum of maternal health service delivery at provincial and district level in South Africa

The continuum of care is a recommended framework for comprehensive health service delivery for maternal health, and it integrates health system and social determinants of health. There is a current lack of knowledge on a measurement approach to monitor performance on the framework. In this study we aim to develop and test a composite index for assessing the maternal health continuum in a province in South Africa with the possibility of nationwide use

Development of a supported self-management intervention for adults with type 2 diabetes and a learning disability

Background: Although supported self-management is a well-recognised part of chronic disease management, it has not been routinely used as part of healthcare for adults with a learning disability. We developed an intervention for adults with a mild or moderate learning disability and type 2 diabetes, building on the principles of supported self-management with reasonable adjustments made for the target population. Methods: In five steps, we: 1. Clarified the principles of supported self-management as reported in the published literature 2. Identified the barriers to effective self-management of type 2 diabetes in adults with a learning disability 3. Reviewed existing materials that aim to support self-management of diabetes for people with a learning disability 4. Synthesised the outputs from the first three phases and identified elements of supported self-management that were (a) most relevant to the needs of our target population and (b) most likely to be acceptable and useful to them 5. Implemented and field tested the intervention Results: The final intervention had four standardised components: (1) establishing the participant’s daily routines and lifestyle, (2) identifying supporters and their roles, (3) using this information to inform setting realistic goals and providing materials to the patient and supporter to help them be achieved and (4) monitoring progress against goals. Of 41 people randomised in a feasibility RCT, thirty five (85%) completed the intervention sessions, with over three quarters of all participants (78%) attending at least three sessions. Twenty-three out of 40 (58%) participants were deemed to be very engaged with the sessions and 12/40 (30%) with the materials; 30 (73%) participants had another person present with them during at least one of their sessions; 15/41 (37%) were reported to have a very engaged main supporter, and 18/41 (44%) had a different person who was not their main supporter but who was engaged in the intervention implementation. Conclusions: The intervention was feasible to deliver and, as judged by participation and engagement, acceptable to participants and those who supported them. Trial registration: Current Controlled Trials ISRCTN41897033 (registered 21/01/2013)

Reliability and validity of emergency department triage systems

Reliability and validity of triage systems is important because this can affect patient safety. In this thesis, these aspects of two emergency department (ED) triage systems were studied as well as methodological aspects in these types of studies. The consistency, reproducibility, and criterion validity of the Manchester Triage System (MTS) were studied in chapter 2. The consistency and reproducibility appeared to be ‘substantial’ and ‘high’. However, substantial percentages mistriage occurred. This was further studied in chapter 3 by reviewing weighting schemes for calculating a weighted kappa. It was found that the existing weighting schemes rewarded mistriage too extensively. Therefore, triage weighted kappa was developed and applied. Triage weighted kappa decreased the reliability of triage systems substantially. Besides these shortcomings, the value of kappa depends on the distribution of the data. Therefore, in chapter 4 an approach was developed on how to interprete and compare the reliability of triage systems. The reliability should be interpreted by plotting the kappa against the minimum, normal, and maximum kappa, to obtain information about the skewness of the data. Comparisons between systems can be made by calculating a normal kappa a so that equal chance corrections are obtained. Because this approach affects sample size calculations, in chapter 5 sample size calculation methods for reliability studies were reviewed. Currently no sample size calculation methods exist for reliability studies conducted to ordinal measurement scales such as triage systems. When calculating sample sizes it is important to take into account the dependence of kappa on the distribution of data by setting the null- and alternative hypothesis to the maximum kappa or by setting the confidence interval width to a maximum of 0.10. In chapter 6 the construct validity of the MTS and Emergency Severity Index (ESI) were studied. The ESI was more strongly associated with hospital admission than the MTS. Concerning ED mortality, patients in the more urgent categories of both systems were at increased risk of dying. A small number of patients did not require ESI resources but were admitted to the hospital or sent to the outpatient department. In chapter 7 it appeared that these patients were most likely elderly, referred, or presenting with ‘post operative complications, wound care problems and plaster problems’. Because of this small but structural flaw the ESI guidelines needs revisions concerning these patient groups. Chapter 8 focussed on pain assessments at triage with the MTS. Pain was assessed in nearly one third of the patients who required an assessment according to the guidelines. Nurses mentioned several reasons for not assessing pain at triage including overtriage, time constraints and difficulties with interpreting pain. The reported reasons indicated that the MTS guidelines should describe more precisely how to assess pain. Although both systems’ guidelines need revisions, the studies described in this thesis indicate that the ESI is more reliable and valid than the MTS. Methodologically, one should critically review existing weighting schemes before applying one, and account for the distribution of data when interpreting reliability. These suggestions will reflect the reliability more in accordance with clinical practice