Considerations of private sector obstetricians on participation in the state led “Chiranjeevi Yojana” scheme to promote institutional delivery in Gujarat, India: a qualitative study

Background In India a lack of access to emergency obstetric care contributes to maternal deaths. In 2005 Gujarat state launched a public-private partnership (PPP) programme, Chiranjeevi Yojana (CY), under which the state pays accredited private obstetricians a fixed fee for providing free intrapartum care to poor and tribal women. A million women have delivered under CY so far. The participation of private obstetricians in the partnership is central to the programme’s effectiveness. We explored with private obstetricians the reasons and experiences that influenced their decisions to participate in the CY programme. Method In this qualitative study we interviewed 24 purposefully selected private obstetricians in Gujarat. We explored their views on the scheme, the reasons and experiences leading up to decisions to participate, not participate or withdraw from the CY, as well as their opinions about the scheme’s impact. We analysed data using the Framework approach. Results Participants expressed a tension between doing public good and making a profit. Bureaucratic procedures and perceptions of programme misuse seemed to influence providers to withdraw from the programme or not participate at all. Providers feared that participating in CY would lower the status of their practices and some were deterred by the likelihood of more clinically difficult cases among eligible CY beneficiaries. Some providers resented taking on what they saw as a state responsibility to provide safe maternity services to poor women. Younger obstetricians in the process of establishing private practices, and those in more remote, ‘less competitive’ areas, were more willing to participate in CY. Some doctors had reservations over the quality of care that doctors could provide given the financial constraints of the scheme. Conclusions While some private obstetricians willingly participate in CY and are satisfied with its functioning, a larger number shared concerns about participation. Operational difficulties and a trust deficit between the public and private health sectors affect retention of private providers in the scheme. Further refinement of the scheme, in consultation with private partners, and trust building initiatives could strengthen the programme. These findings offer lessons to those developing public-private partnerships to widen access to health services for underprivileged groups

‘The money is important but all women anyway go to hospital for childbirth nowadays’ - a qualitative exploration of why women participate in a conditional cash transfer program to promote institutional deliveries in Madhya Pradesh, India

Background In 2005–06, only 39 % of Indian women delivered in a health facility. Given that deliveries at home increase the risk of maternal mortality, it was in this context in 2005, that the Indian Government implemented the Janani Suraksha Yojana program that incentivizes poor women to give birth in a health facility by providing them with a cash transfer upon discharge. JSY helped raise institutional delivery to 74 % in the eight years since its implementation. Despite the success of the JSY in raising institutional delivery proportions, the large number of beneficiaries (105 million), and the cost of the program, there have been few qualitative studies exploring why women participate (or not) in the program. The objective of this paper was to explore this. Methods In March 2013, we conducted 24 individual in-depth interviews with women who delivered within the previous 12 months in two districts of Madhya Pradesh, India. Qualitative framework analysis was used to analyze the data. Results Our findings suggest that women’s increased participation in the program reflect a shift in the social norm. Drivers of the shift include social pressure from the Accredited Social Health Activist (ASHA) to deliver in a health facility, and a growing individual perception of the importance for ‘safe’ and ‘easy’ delivery which was most likely an expression of the new social norm. While the incentive was an important influence on many women’s choices, others did not perceive it as an important consideration in their decision to deliver in a health facility. Many women reported procedural difficulties to receive the benefit. Retaining the cash incentive was also an issue due to out-of-pocket expenditures incurred at the facility. Non-participation was often unintentional and caused by personal circumstances, poor geographic access or driven by a perception of poor quality of care provided in program facilities. Conclusions In summary, while the cash incentive was important for some women in facilitating an institutional birth, the shift in social norm (possibly in part facilitated by the program) and therefore their own perceptions has played a major role in them giving birth in facilities

Participation in the state led '<i>Janani Sahayogi Yojana'</i> public private partnership program to promote facility births in Madhya Pradesh, India: views from private obstetrician partners

BackgroundIn Madhya Pradesh, India, the government invited private obstetric hospitals for partnership to provide intrapartum care to poor women, paid for by the state. This statewide program, the Janani Sahayogi Yojana (JShY or maternal support scheme), ran from 2006 to 2012. The partnership was an uneasy one with many private obstetricians choosing to leave the partnership. This paper explores the motives of private obstetricians in the state for participating in the JShY, their experiences within the partnership, their interactions with the state and motives for withdrawal among those who withdrew from the scheme. This study sheds light on the dynamics of a public-private partnership for obstetric care from the perspective of private sector obstetricians.MethodFifteen in-depth interviews were conducted with private obstetricians and hospital administrators from eight districts of Madhya Pradesh who had participated in the JShY. A Framework approach was used to analyze the data.ResultsPrivate obstetricians reported entering the JShY partnership for altruistic reasons but also as way of expanding their practices and reputations. They perceived that although their facilities provided better quality of care than state facilities, participation was risky because beneficiaries were often unbooked and seen as 'high risk' cases. The need to arrange for blood transfusions for these high risk women was perceived as particularly difficult. Cumbersome paper work and delays in receiving payments from the state also dissuaded participation. Some participants felt that there was inadequate engagement by the state, and better monitoring and supervision would have helped. The state changed the financial reimbursement arrangements due to a high proportion of Cesarean births in the early years of the partnership, as these were perversely incentivized. This change resulted in a large exodus of private obstetricians from the partnership.ConclusionThis study highlights the contribution of cumbersome processes, trust deficits and a lack of dialogue between public and private partners. Input from both public and private sectors into the design of a carefully thought through financial reimbursement package for private partners was highlighted as a necessary component for future success of such schemes

'Pneumonia has gone': exploring perceptions of health in a cookstove intervention trial in rural Malawi

Introduction Air pollution through cooking on open fires or inefficient cookstoves using biomass fuels has been linked with impaired lung health and with over 4 million premature deaths per annum. However, use of cleaner cookstoves is often sporadic and there are indications that longer-term health benefits are not prioritised by users. There is also limited information about how recipients of cookstoves perceive the health benefits of clean cooking interventions. We therefore conducted a qualitative study alongside the Cooking and Pneumonia Study (CAPS). Methods Qualitative methods and the participatory methodology Photovoice were used in an in-depth examination of health perceptions and understandings of CAPS trial participants. Fifty participants in five CAPS intervention villages collected images about cooking. These were discussed in village-level focus groups and in interviews with 12 representative participants. Village community representatives were also interviewed. Four female and eight male CAPS fieldworkers took part in gender-specific focus groups and two female and two male fieldworkers were interviewed. A thematic content approach was used for data analysis. Results We found a disconnect between locally situated perceptions of health and the biomedically focused trial model. This included the development of potentially harmful understandings such as that pneumonia was no longer a threat and potential confusion between the symptoms of pneumonia and malaria. Study participants perceived health and well-being benefits including: cookstoves saved bodily energy; quick cooking helped maintain family harmony. Conclusion A deeper understanding of narratives of health within CAPS showed how context-specific perceptions of the health benefits of cookstoves were developed. This highlighted the conflicting priorities of cookstove intervention researchers and participants, and unintended and potentially harmful health understandings. The study also emphasises the importance of including qualitative explorations in similar complex interventions where potential pathways to beneficial (and harmful) effects, cannot be completely explicated through biomedical models alone

'Cooking is for everyone?': Exploring the complexity of gendered dynamics in a cookstove intervention study in rural Malawi

BACKGROUND Household air pollution (HAP) resulting from cooking on open fires has been linked to considerable ill-health in women and girls, including chronic respiratory diseases, and has been identified as a contributor to climate change. It has been suggested that cleaner burning cookstoves can mitigate these risks, and that time saved through speedier cooking can lead to the economic empowerment of women. Despite these and other potential advantages of cookstoves, sustained use is difficult to achieve. OBJECTIVE We used qualitative methods (focus groups, interviews, observation) and the participatory methodology Photovoice in order to inform a deeper understanding of gendered social relationships within the Cooking and Pneumonia Study (CAPS) in rural Malawi. METHODS Over five CAPS villages, forty women and ten men were recruited for Photovoice activities, including image collection, village-level focus group discussion and interviews. Data were also collected from interviews with village-based community representatives. RESULTS This study facilitated a rich exploration of context-specific gendered household roles and power relations which found that there was space for contestation in seemingly entrenched and 'traditional' household responsibilities. The results suggest that the introduction of cookstoves through CAPS provided a focus for this contestation. It was evident that men and children also cooked, and that cooking played a central role in the gendered socialisation of children. However, there were no indications that time saved resulted in the empowerment of women. CONCLUSION Our findings suggest that dominant narratives of the links between gender and cookstoves are often reductive and fail to reflect the complexity of gender power relations. The use of qualitative methods incorporating Photovoice helped to facilitate an alternative 'bottom-up' view of cookstove use which demonstrated that while cookstoves may disrupt gendered relationships in target communities, positive impacts for women and girls cannot be assumed

Health professionals' experiences of tuberculosis cohort audit in the North West of England : a qualitative study

This research was supported by Public Health England and the Centre for Applied Health Research and Delivery, Liverpool School of Tropical Medicine (LSTM).Objectives. Tuberculosis cohort audit (TBCA) was introduced across the North West (NW) of England in 2012 as an ongoing, multidisciplinary, systematic case review process, designed to improve clinical and public health practice. TBCA has not previously been introduced across such a large and socioeconomically diverse area in England, nor has it undergone formal, qualitative evaluation. This study explored health professionals' experiences of the process after 1515 cases had been reviewed. Design. Qualitative study using semistructured interviews. Respondents were purposively sampled from 3 groups involved in the NW TBCA: (1) TB nurse specialists, (2) consultant physicians and (3) public health practitioners. Data from the 26 respondents were triangulated with further interviews with key informants from the TBCA Steering Group and through observation of TBCA meetings. Analysis. Interview transcripts were analysed thematically using the framework approach. Results. Participants described the evolution of a valuable 'community of practice' where interprofessional exchange of experience and ideas has led to enhanced mutual respect between different roles and a shared sense of purpose. This multidisciplinary, regional approach to TB cohort audit has promoted local and regional team working, exchange of good practices and local initiatives to improve care. There is strong ownership of the process from public health professionals, nurses and clinicians; all groups want it to continue. TBCA is regarded as a tool for quality improvement that improves patient safety. Conclusions. TBCA provides peer support and learning for management of a relatively rare, but important infectious disease through discussion in a no-blame atmosphere. It is seen as an effective quality improvement strategy which enhances TB care, control and patient safety. Continuing success will require increased engagement of consultant physicians and public health practitioners, a secure and ongoing funding stream and establishment of clear reporting mechanisms within the public health system.Publisher PDFPeer reviewe

Technology Adoption of Computer-Aided Instruction in Healthcare: A Structured Review

Computer-Aided Instruction (CAI) is one of the interactive teaching methods that electronically presents instructional resources and enhances learner performance. In health settings, using CAI is one of the important ways to improve learners\u27 knowledge and usefulness in their healthcare specialization yet there is still a lack of research that offers a comprehensive synthesis of investigating into the adoption of CAI in healthcare. This research aims to provide a comprehensive review of related literatures on the enablers and barriers for technology adoption of CAI in healthcare. 31 journals were analyzed and revealed that several studies were utilizing the Unified Theory of Acceptance and Use of Technology (UTAUT). The researchers then conducted qualitative coding for thematic analysis and categorized the qualitative data to find themes and patterns. Enablers as well as barriers to CAI adoption in healthcare were then discussed along with the common conclusions, limitations and recommendations for future studies. Results shows that key enablers were perceived ease of use, ease of usefulness, performance expectancy, social influence, user experience, and effort expectancy while identified key barriers were government support, funding constraints, and interactivity. The majority of the research articles highlighted the benefits of CAI in healthcare education as an innovative method for boosting the effectiveness of both teaching and learning

Technology Adoption of Computer-Aided Instruction in Healthcare: A Structured Review

Computer-Aided Instruction (CAI) is one of the interactive teaching methods that electronically presents instructional resources and enhances learner performance. In health settings, using CAI is one of the important ways to improve learners’ knowledge and usefulness in their healthcare specialization yet there is still a lack of research that offers a comprehensive synthesis of investigating into the adoption of CAI in healthcare. This research aims to provide a comprehensive review of related literatures on the enablers and barriers for technology adoption of CAI in healthcare. 31 journals were analyzed and revealed that several studies were utilizing the Unified Theory of Acceptance and Use of Technology (UTAUT). The researchers then conducted qualitative coding for thematic analysis and categorized the qualitative data to find themes and patterns. Enablers as well as barriers to CAI adoption in healthcare were then discussed along with the common conclusions, limitations and recommendations for future studies. Results shows that key enablers were perceived ease of use, ease of usefulness, performance expectancy, social influence, user experience, and effort expectancy while identified key barriers were government support, funding constraints, and interactivity. The majority of the research articles highlighted the benefits of CAI in healthcare education as an innovative method for boosting the effectiveness of both teaching and learning

Durable response with single-agent acalabrutinib in patients with relapsed or refractory mantle cell lymphoma

Bruton tyrosine kinase (BTK) inhibitors have greatly improved the spectrum of treatment options in mantle cell lymphoma (MCL) [1–4]. Acalabrutinib is a highly selective, orally administered, and potent BTK inhibitor with limited off-target activity [5]. Acalabrutinib was approved in 2017 by the US Food and Drug Administration for the treatment of relapsed/refractory MCL based on clinical data from the open-label, multicenter, phase 2 ACE-LY-004 study of acalabrutinib 100 mg twice daily [1]. Here, we present updated results from the ACE-LY-004 study after a median 26-month follow-up. Eligibility criteria and study design were published previously (Supplementary methods) [1]. Analysis of minimal residual disease (MRD) was conducted after complete response (CR) or partial response (PR) was achieved using the quantitative ClonoSEQ next-generation sequencing (5 × 10−6 ) assay (Adpative Biotechnologies, Seattle, WA, USA) in consenting patients with available paired archival tumor and whole blood samples. Data are updated as of February 12, 2018