Stages of change: A qualitative study on the implementation of a perinatal audit programme in South Africa

<p>Abstract</p> <p>Background</p> <p>Audit and feedback is an established strategy for improving maternal, neonatal and child health. The Perinatal Problem Identification Programme (PPIP), implemented in South African public hospitals in the late 1990s, measures perinatal mortality rates and identifies avoidable factors associated with each death. The aim of this study was to elucidate the processes involved in the implementation and sustainability of this programme.</p> <p>Methods</p> <p>Clinicians' experiences of the implementation and maintenance of PPIP were explored qualitatively in two workshop sessions. An analytical framework comprising six stages of change, divided into three phases, was used: pre-implementation (create awareness, commit to implementation); implementation (prepare to implement, implement) and institutionalisation (integrate into routine practice, sustain new practices).</p> <p>Results</p> <p>Four essential factors emerged as important for the successful implementation and sustainability of an audit system throughout the different stages of change: 1) drivers (agents of change) and team work, 2) clinical outreach visits and supervisory activities, 3) institutional perinatal review and feedback meetings, and 4) communication and networking between health system levels, health care facilities and different role-players.</p> <p>During the pre-implementation phase high perinatal mortality rates highlighted the problem and indicated the need to implement an audit programme (stage 1). Commitment to implementing the programme was achieved by obtaining buy-in from management, administration and health care practitioners (stage 2).</p> <p>Preparations in the implementation phase included the procurement and installation of software and training in its use (stage 3). Implementation began with the collection of data, followed by feedback at perinatal review meetings (stage 4).</p> <p>The institutionalisation phase was reached when the results of the audit were integrated into routine practice (stage 5) and when data collection had been sustained for a longer period (stage 6).</p> <p>Conclusion</p> <p>Insights into the factors necessary for the successful implementation and maintenance of an audit programme and the process of change involved may also be transferable to similar low- and middle-income public health settings where the reduction of the neonatal mortality rate is a key objective in reaching Millennium Development Goal 4. A tool for reflecting on the implementation and maintenance of an audit programme is also proposed.</p

Toxigenic potential of Fusarium graminearum isolated from maize of northwest Argentina

Twenty six isolates of Fusarium graminearum from grains of maize hybrids harvested in ±west Argentina were grown on autoclaved rice grain to assess their ability to produce type B trichothecenes. Chemical analysis indicated that 38% of isolates were nivalenol (NIV) producers only, 31% were major NIV producers with high DON(deoxynivalenol)/NIV ratios, 8% were major DON producers with minor NIV production, and 23% were DON producers only. Isolates showed a high variability in their toxigenic potential which was not related to fungal biomass. The distribution of the different chemotypes as well as the high and the low trichothecene-producing Fusarium isolates could not be associated to a geographical origin. Our results confirmed for the first time that isolates of Fusarium graminearum from maize of northwest Argentina are able to produce DON and NIV. A substancial contamination with both NIV and DON is likely in maize from northwest Argentina. Their contents should be quantified in regional surveillances for mycotoxin contamination.Fil: Sampietro, Diego Alejandro. Universidad Nacional de Tucumán. Facultad de Bioquímica, Química y Farmacia; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Apud, Gisselle Raquel. Universidad Nacional de Tucumán. Facultad de Bioquímica, Química y Farmacia; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Belizán, María Melina Eleonora. Universidad Nacional de Tucumán. Facultad de Bioquímica, Química y Farmacia; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Vattuone, Marta Amelia. Universidad Nacional de Tucumán. Facultad de Bioquímica, Química y Farmacia; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Catalan, Cesar Atilio Nazareno. Universidad Nacional de Tucumán. Facultad de Bioquímica, Química y Farmacia; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Tucumán. Instituto de Quimica del Noroeste; Argentina; Argentin

The development of the WHO Labour Care Guide: an international survey of maternity care providers

Background: The partograph is the most commonly used labour monitoring tool in the world. However, it has been used incorrectly or inconsistently in many settings. In 2018, a WHO expert group reviewed and revised the design of the partograph in light of emerging evidence, and they developed the first version of the Labour Care Guide (LCG). The objective of this study was to explore opinions of skilled health personnel on the first version of the WHO Labour Care Guide. Methods: Skilled health personnel (including obstetricians, midwives and general practitioners) of any gender from Africa, Asia, Europe and Latin America were identified through a large global research network. Country coordinators from the network invited 5 to 10 mid-level and senior skilled health personnel who had worked in labour wards anytime in the last 5 years. A self-administered, anonymous, structured, online questionnaire including closed and open-ended questions was designed to assess the clarity, relevance, appropriateness of the frequency of recording, and the completeness of the sections and variables on the LCG. Results: A total of 110 participants from 23 countries completed the survey between December 2018 and January 2019. Variables included in the LCG were generally considered clear, relevant and to have been recorded at the appropriate frequency. Most sections of the LCG were considered complete. Participants agreed or strongly agreed with the overall design, structure of the LCG, and the usefulness of reference thresholds to trigger further assessment and actions. They also agreed that LCG could potentially have a positive impact on clinical decision-making and respectful maternity care. Participants disagreed with the value of some variables, including coping, urine, and neonatal status. Conclusions: Future end-users of WHO Labour Care Guide considered the variables to be clear, relevant and appropriate, and, with minor improvements, to have the potential to positively impact clinical decision-making and respectful maternity care.Fil: Pingray, María Verónica. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Bonetto, Mercedes. Organizacion Mundial de la Salud; ArgentinaFil: Berrueta, Amanda Mabel. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Mazzoni, Agustina. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Belizán, María. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Keil, Netanya. Nyu Abu Dhabi; Emiratos Arabes UnidosFil: Vogel, Joshua. Burnet Institute; AustraliaFil: Althabe, Fernando. Organizacion Mundial de la Salud; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; ArgentinaFil: Oladapo, Olufemi T.. Organizacion Mundial de la Salud; Argentin

Antinociceptive, anti-inflammatory effects and safety of Ziziphus mistol fruits

Ziziphus mistol Griseb. (Rhamnaceae), popularly known as ?mistol,? is widely distributed throughout Perú, Bolivia, Paraguay and Argentina. Its fruit is consumed in different forms in several argentinean communities. The present study was carried out to investigate the medicinal properties and safety of Ziziphus mistol (mistol) fruits ethanol and aqueous extracts and arrope. Antinociceptive activity was assessed using the formalin, acetic acid-induced writhing and tail-flick tests in rats. Anti-inflammatory effects were determinated through carrageenan induced edema test and cotton pellet-induced granuloma formation, in rats. The safety was evaluated with test of acute toxicity (48 hs) and sub-chronic toxicity (91 days).All extracts (1,000 mg / kg body weight) showed significant inhibition (P <0.05) in the pain and inflammation experimentally induced. In the acute toxicity study, a single dose of 4000 and 8000 mg/kg b.w., produced no mortality and no clinical signs of disease were observed after 48 h. In the sub-chronic toxicity study the extracts no caused significant visible signs of toxicity, nor mortality for 91 consecutive days of treatment. No significant differences were found in relative organ weights and hematological and biochemical parameters between the treated groups and the control groups. Aqueous extract and arrope of Z. mistol fruits could be good source of antinociceptive and anti-inflamatory agents because of its good activity and safety.Fil: Reynoso, Marcos Adrian. Universidad Nacional de Tucumán. Facultad de Bioquímica, Química y Farmacia. Instituto de Biología; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Tucumán; ArgentinaFil: Daud, Adriana del Valle. Universidad Nacional de Tucumán. Facultad de Bioquímica, Química y Farmacia. Instituto de Biología; ArgentinaFil: Belizán, María Melina Eleonora. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Tucumán; Argentina. Universidad Nacional de Tucuman. Facultad de Bioquímica, Química y Farmacia. Instituto de Farmacia. Cátedra de Farmacoquímica; ArgentinaFil: Sánchez Riera, Alvaro. Universidad Nacional de Tucumán. Facultad de Bioquímica, Química y Farmacia. Instituto de Biología; ArgentinaFil: Vera, Nancy Roxana. Universidad Nacional de Tucuman. Facultad de Bioquímica, Química y Farmacia. Instituto de Farmacia. Cátedra de Farmacoquímica; Argentin

Theory-driven, rapid formative research on quality improvement intervention for critical care of patients with COVID-19 in Argentina

The challenges of implementing interventions in healthcare settings have been more apparent during the COVID-19 pandemic. This pre-implementation evaluation used a rapid qualitative approach to explore barriers and facilitators to an intervention in intensive care units in Argentina, aimed to promote the use of personal protection equipment, provide emotional support for professionals, and achieve patient flow goals. Data were collected using semi-structured interviews with health professionals of 15 public hospitals in Argentina. Normalization Process Theory was used to guide content analysis of the data. Participants identified potential barriers such as the incorporation of non-specialist staff, shortage of resources, lack of communication between groups and shifts. Potential facilitators were also identified: regular feedback and communication related to implementation, adequate training for new and non-specialist staff, and incentives (e.g., scholarships). The immediacy of the pandemic demanded rapid qualitative research, sharing actionable findings in real time.Fil: Roberti, Javier Eugenio. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; ArgentinaFil: Jorro Baron, Facundo Ariel. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Rodríguez, Viviana Rita. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Belizán, María. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Arias, Pilar. No especifíca;Fil: Ratto, María Elena. No especifíca;Fil: Reina, Rosa. No especifíca;Fil: Ini, Natali Denise. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; Argentina. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Loudet, Cecilia. No especifíca;Fil: Garcia Elorrio, Ezequiel. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; Argentina. Instituto de Efectividad Clínica y Sanitaria; Argentin

Gaps between calcium recommendations to prevent pre-eclampsia and current intakes in one hospital in Argentina

Background: Hypertensive disorders are a major cause of maternal mortality. In Latin America and the Caribbean, pre-eclampsia accounts for approximately one in every four maternal deaths. The World Health Organization recommends calcium supplementation during pregnancy for the prevention and treatment of pre-eclampsia and eclampsia in locations where dietary calcium intake is low. Calcium intake in Argentina is reported to be below WHO recommended levels; however, calcium intake from supplements and water has not been fully evaluated.The objective of this study was to evaluate calcium intake from supplements and water in a group of pregnant women. Methods: This cross-sectional study was conducted at a maternity hospital in the city of Buenos Aires, Argentina. Questionnaires were verbally administered to women attending a routine antenatal care visit. Participants were 18 years of age or older and in their third trimester of pregnancy. Participants were first interviewed to evaluate nutritional supplement consumption and a subgroup was invited to undergo a 24-hour dietary recall. Results: 137 women meeting inclusion criteria consented to participate.The average participant age was 27 years (SD ± 5.9), and all resided in an urban setting. None of the subjects took calcium supplements specifically, although 24 (17%) recalled taking supplements or antacids which contributed to their calcium intake. Mean calcium intake was 663mg SD ±389 for those women completing the 24-hour dietary recall,. This value increased to 706 mg SD ±387 upon considering water intake and measuring chemical composition of water from the areas where women lived at the time of the interview and was further increased to 719 mg (SD ±392) when calcium from supplements was taken into consideration. Conclusions: None of the subjects were consuming calcium supplements. Taking into account the low calcium intake in this population, diverse strategies would be required to comply with recommendations.Facultad de Ciencias ExactasFacultad de Ingenierí

Abordagem da doença de Chagas na Atenção Primária: pesquisa qualitativa em uma Área Endêmica da Argentina

El objetivo de este estudio fue evaluar la percepción de equipos de salud de atención en primer nivel y público objetivo acerca de facilitadores y barreras para el abordaje de Chagas a partir de una intervención multifacética, en una zona endémica. Se realizaron 12 entrevistas semiestructuradas y grupos focales en Centros de Atención Primaria en Resistencia, Chaco. El estudio fue guiado por el Marco Consolidado para la Investigación de la Implementación. Los profesionales tuvieron una impresión positiva de la intervención pero mostraron preocupación acerca de la factibilidad. Los profesionales perciben un número excesivo de programas, pocos insumos y recursos humanos, insuficiente capacitación, material informativo desactualizado, trabas burocrática para pedido de insumos y medicación; asimismo perciben falta de vinculación en niveles de atención y fragmentación de registros. Esta investigación contribuiría a la adaptación de intervenciones según barreras y facilitadores existentes.The objective of this study was to evaluate the perception of the healthcare teams and target population about the facilitators and barriers to address Chagas disease in primary level in an endemic area in Argentina. Twelve semi-structured interviews and focus groups were conducted in Primary Health Care Centres in Resistencia, Chaco. The study was guided by the Consolidated Framework for Implementation Research. While professionals had a positive perception of the proposed intervention to address Chagas, they showed concern about complexity and feasibility. Professionals perceive an excessive number of programs, limited material and resources, a lack of training in Chagas, outdated information material, bureaucratic obstacles to requesting supplies and medication, unrelated levels of care and fragmented records on Chagas. This research would contribute to the design of interventions that can be adapted to the existing barriers and facilitators.O objetivo deste estudo foi avaliar a percepção das equipes de saúde e da população alvo sobre os facilitadores e as barreiras para enfrentar a doença de Chagas ao nível primário em uma área endêmica na Argentina. Foram realizadas 12 entrevistas semiestruturadas e grupos focais em Centros de Saúde Primários em Resistencia, Chaco. O estudo foi orientado pelo Quadro Consolidado de Pesquisa para Implementação. Os profissionais tiveram uma percepção positiva da intervenção proposta para abordar o Chagas, mas mostraram preocupação com a sua complexidade e viabilidade. Os profissionais percebem um número excessivo de programas, material e recursos limitados, falta de treinamento em Chagas, material informativo desatualizado, obstáculos burocráticos para solicitar suprimentos e medicamentos, níveis de cuidados não relacionados e registros fragmentados sobre Chagas. Esta investigação contribuiria para a concepção de intervenções que possam ser adaptadas às barreiras e facilitadores existentes.Fil: Roberti, Javier Eugenio. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Alonso, Juan Pedro. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Rouvier, Mariel Vanesa. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Belizán, María Melina Eleonora. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Klein, Karen. Instituto de Efectividad Clínica y Sanitaria; Argentin

Health care providers perspectives about maternal immunization in Latin America

Background: Antenatal care providers have a key role in providing appropriate information and immunization recommendations to improve pregnant women's vaccine uptake. The objective of this study is to describe health care providers' perspectives and experience regarding the implementation of maternal immunization programs in Latin America. Methods: We conducted 33 in-depth interviews of health care providers from Argentina, Brazil, Honduras, Mexico, and Peru (6–7 per country). Qualitative data analysis was conducted using a combination of both manual techniques and the computer software program NVivo. We identified and coded main themes related to maternal immunization. Results: The main themes identified in this analysis were practices related to maternal immunization, knowledge and training, resource availability and interactions with pregnant women. Healthcare providers knew that recommendations exists but some did not know their content; they expressed concerns about insufficient training. Providers from all five countries expressed the need for additional human resources and supplies. They also expressed a desire for women to be more proactive and ask more questions during the health visits. Conclusion: This is the first multi-country study assessing the perspectives of health care providers about maternal immunization practices at the facility level in Latin America. Recommendations based on the results from this study include implementing additional trainings around maternal immunization, especially targeting obstetricians and midwives. These trainings should be conducted in coordination with improvements to supply chain and other structural issues.Fil: Malik, Fauzia A.. University of Yale; Estados UnidosFil: Alonso, Juan Pedro. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Sanclemente, Lauren N.. University of Emory; Estados UnidosFil: Vilajeliu, Alba. Organización Panamericana de la Salud; Estados UnidosFil: Gutierrez, Mariana. University of Emory; Estados UnidosFil: Gonzalez Casanova, Ines. University of Emory; Estados Unidos. Indiana University; Estados UnidosFil: Jones, Daniel Eduardo. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Omer, Saad. University of Yale; Estados UnidosFil: Ropero, Alba-Maria. Organización Panamericana de la Salud; Estados UnidosFil: Belizán, María Melina Eleonora. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentin

Pesquisa formativa para a estruturação e implementação de uma estratégia para aumentar o rastreamento do câncer colorretal no local de trabalho na Argentina

El ámbito laboral tiene un gran potencial para difundir información e implementar actividades de promoción de la salud, como la prevención y detección temprana del cáncer. Debido al desafío de implementar intervenciones sanitarias en este ámbito, se necesitan investigaciones formativas para adecuar el diseño y la implementación de las estrategias para que sean exitosas. Con el objetivo de informar el diseño e implementación de la intervención, para mejorar la tasa de adherencia al tamizaje con el test de sangre oculta en materia fecal, en un ámbito laboral en Argentina, se realizó una investigación formativa para identificar potenciales barreras y facilitadores. La investigación formativa siguió un diseño metodológico cualitativo. Se realizaron entrevistas con 10 responsables de áreas clave de la institución en que se desarrolló el estudio y 8 grupos focales con trabajadores mayores de 50 años. Se identificaron desafíos para la implementación de la intervención en el nivel institucional, como la dispersión geográfica de los trabajadores y la complejidad del organigrama de la institución, y en el nivel de la población objetivo, como el bajo conocimiento del cáncer colorrectal y de los test diagnósticos, así como la baja percepción de riesgo. Entre los facilitadores se destacaron la aceptabilidad de la intervención, además de la disponibilidad de recursos humanos y materiales para llevar adelante la intervención, como canales de comunicación institucional para la diseminación de información, así como la logística para la distribución de kits diagnósticos. La investigación formativa permitió relevar recursos e identificar potenciales barreras que informaron el diseño y la implementación de la intervención.The workplace has great potential to disseminate information and implement health promotion activities such as cancer prevention and early detection. Due to the challenges of deploying health interventions in this setting, formative studies are needed to adjust the design and implementation of successful strategies. To inform the intervention’s design and implementation and improve the adherence rate to screening with fecal occult blood test in a workplace in Argentina, a formative study was conducted to identify potential barriers and facilitators. The formative study adopted a qualitative methodological design. Interviews were held with 10 individuals in charge of key areas in the institution where the main study was conducted, besides 8 focus groups with workers over 50 years of age. Challenges were identified at the institutional level for the intervention’s implementation, such as workers’ geographic dispersion and the complexity of the institution’s flowchart, as well as at the population level, such as low knowledge about colorectal cancer and diagnostic tests and low risk perception. The facilitators featured the intervention’s acceptability and the availability of human and material resources to proceed with the intervention, such as institutional communications channels for disseminating the information and logistics for distribution of diagnostic kits. The formative study allowed identifying resources and potential barriers that informed the intervention’s design and implementation.O local de trabalho possui grande potencial para divulgar informação e implementar atividades de promoção da saúde, como a prevenção e detecção precoce do câncer. Frente ao desafio de implementar ações sanitárias naquele ambiente, são necessárias pesquisas formativas para adequar a estruturação e a implementação das estratégias para que sejam bem-sucedidas. Com o objetivo de subsidiar a concepção e a implementação da ação, visando melhorar a taxa de aderência ao screening com o teste de sangue oculto nas fezes no ambiente de trabalho na Argentina, foi desenvolvida uma pesquisa formativa para identificar potenciais barreiras e facilitadores. A pesquisa formativa seguiu um formato metodológico qualitativo. Foram realizadas entrevistas com 10 gerentes de áreas chaves da entidade onde foi desenvolvido o estudo e 8 grupos focais, com trabalhadores acima de 50 anos de idade. Foram identificados alguns desafios para a implementação de uma ação em nível institucional, como a dispersão geográfica dos trabalhadores e a complexidade do organograma da entidade, e em termos de população objetiva, como o baixo conhecimento a respeito do câncer colorretal e dos testes diagnósticos, além da baixa percepção de risco. Entre os facilitadores, destacaram-se a aceitabilidade da ação e a disponibilidade de recursos humanos e materiais para levar a cabo a ação, como canais de comunicação institucional, para a divulgação da informação e a logística, para a distribuição dos kits diagnósticos. A pesquisa formativa revelou recursos e identificou potenciais barreiras, ajudando na estruturação e implementação da ação.Fil: Alonso, Juan Pedro. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Universidad de Buenos Aires. Facultad de Ciencias Sociales. Instituto de Investigaciones "Gino Germani"; ArgentinaFil: Belizán, María. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Comolli, Mariana. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: González, Lucas. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Roberti, Javier Eugenio. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; ArgentinaFil: Pichón-Riviere, Andrés. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Bardach, Ariel Esteban. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Instituto de Efectividad Clínica y Sanitaria; Argentin