Towards health systems resilience to extreme weather events : managing health needs during floods in Cambodia

Background: Extreme weather events like floods are expected to become more common as climate change continues, putting health at risk. Knowledge on what health needs are expected after such events is needed for health systems to be able to provide health services. Resilient health systems have the capacity to maintain their functions and change when experiencing events like floods which enables them to continue delivering essential health services. Enabling resilience in health systems requires an understanding of what capacities create resilience. Aim: To assess the effects of flooding on health and the capacity of the public health system to manage health needs during floods in Cambodia, with a view to identifying capacities that foster health systems resilience to extreme weather events. Methods: Study I was a systematic review of epidemiologic articles (n=113) to identify changes in health outcomes of affected people after flood or storm disasters globally, analysed by narrative synthesis. Study II was a time series analysis of monthly visits to public healthcare facilities in eleven districts in Cambodia for acute respiratory infections, diarrhea, skin infections, noncommunicable diseases, injuries, and vector-borne diseases between 2008 and 2013. Poisson regression models were used to quantify their relationship with the extent of flood water in each district. In Study III, focus group discussions (n=8) and semi-structured interviews (n=17) with community members who had experience with pregnancy or childbirth during floods were used to understand if and how the public health system’s capacity to absorb, adapt, or transform is linked to the community’s own capacity when managing antenatal and childbirth care needs during seasonal and occasional floods. The data were analysed by thematic analysis. In Study IV, 23 semi-structured interviews were conducted with public sector staff with experience providing or managing antenatal or childbirth care services during floods. They were analysed by thematic analysis to generate knowledge on the influences on public sector health service delivery in Cambodia during seasonal and occasional floods that are related to the system’s capacity to absorb, adapt, or transform. Results: There is some evidence that flood and storm disasters affect health for up to two years, and that floods and storms may affect health differently (Study I). In Cambodia, visits to healthcare facilities for diarrhea, acute respiratory infections, and skin infections increased immediately and up to three months after seasonal and occasional floods (Study II). The community was primarily capable of absorbing the impact of seasonal and occasional floods on their antenatal and childbirth care needs, which was linked to their responsibility to balance the expectations placed on them to receive care during floods but with limited support and help (Study III). Collaboration and relationships have created boundaries around decision-making that allow a stable but flexible approach to public antenatal and birth health services in Cambodia when regularly exposed to floods (Study IV). Conclusions: Floods had a prolonged effect on health, increasing new and routine health needs globally and increasing new health needs in Cambodia for up to three months after repeated seasonal and occasional floods. The public sector of the Cambodian health system appeared to have the capacity to absorb and adapt in order to manage antenatal and childbirth health needs during seasonal and occasional floods. They were aided by the community’s own capacity to absorb that helped relieve the health system’s responsibility to manage health needs. Strategies that enhance stability and flexibility in contexts where extreme weather events are perceived as strains rather than shocks may enhance system capacities for resilience. Public health system support to communities during floods and involvement in decision-making may generate resilience capacities in the community, strengthening the health system’s resilience to repeated extreme weather events

Health System Resilience: What Are We Talking About? A Scoping Review Mapping Characteristics and Keywords

Background: Health systems are based on 6 functions that need to work together at all times to effectively deliver safe and quality health services. These functions are vulnerable to shocks and changes; if a health system is unable to withstand the pressure from a shock, it may cease to function or collapse. The concept of resilience has been introduced with the goal of strengthening health systems to avoid disruption or collapse. The concept is new within health systems research, and no common description exists to describe its meaning. The aim of this study is to summarize and characterize the existing descriptions of health system resilience to improve understanding of the concept.Methods and Analysis: A scoping review was undertaken to identify the descriptions and characteristics of health system resilience. Four databases and gray literature were searched using the keywords “health system” and “resilience” for published documents that included descriptions, frameworks or characteristics of health system resilience. Additional documents were identified from reference lists. Four expert consultations were conducted to gain a broader perspective. Descriptions were analysed by studying the frequency of key terms and were characterized by using the World Health Organization (WHO) health system framework. The scoping review identified eleven sources with descriptions and 24 sources that presented characteristics of health system resilience. Frequently used terms that were identified in the literature were shock, adapt, maintain, absorb and respond. Change and learning were also identified when combining the findings from the descriptions, characteristics and expert consultations. Leadership and governance were recognized as the most important building block for creating health system resilience.Discussion: No single description of health system resilience was used consistently. A variation was observed on how resilience is described and to what depth it was explained in the existing literature. The descriptions of health system resilience primarily focus on major shocks. Adjustments to long-term changes and the element of learning should be considered for a better understating of health system resilience

The Effect of Seasonal Floods on Health: Analysis of Six Years of National Health Data and Flood Maps.

There is limited knowledge on the effect of seasonal flooding on health over time. We quantified the short- and long-term effects of floods on selected health indicators at public healthcare facilities in 11 districts in Cambodia, a flood-prone setting. Counts of inpatient discharge diagnoses and outpatient consultations for diarrhea, acute respiratory infections, skin infections, injuries, noncommunicable diseases and vector-borne diseases were retrieved from public healthcare facilities for each month between January 2008 and December 2013. Flood water was mapped by month, in square kilometers, from satellite data. Poisson regression models with three lag months were constructed for the health problems in each district, controlled for seasonality and long-term trends. During times of flooding and three months after, there were small to moderate increases in visits to healthcare facilities for skin infections, acute respiratory infections, and diarrhea, while no association was seen at one to two months. The associations were small to moderate, and a few of our results were significant. We observed increases in care seeking for diarrhea, skin infections, and acute respiratory infections following floods, but the associations are uncertain. Additional research on previous exposure to flooding, using community- and facility-based data, would help identify expected health risks after floods in flood-prone settings

‘We have a plan for that’: a qualitative study of health system resilience through the perspective of health workers managing antenatal and childbirth services during floods in Cambodia.

OBJECTIVE: Health system resilience can increase a system's ability to deal with shocks like floods. Studying health systems that currently exhibit the capacity for resilience when shocked could enhance our understanding about what generates and influences resilience. This study aimed to generate empirical knowledge on health system resilience by exploring how public antenatal and childbirth health services in Cambodia have absorbed, adapted or transformed in response to seasonal and occasional floods. DESIGN: A qualitative study using semi-structured interviews and thematic analysis and informed by the Dimensions of Resilience Governance framework. SETTING: Public sector healthcare facilities and health departments in two districts exposed to flooding. PARTICIPANTS: Twenty-three public sector health professionals with experience providing or managing antenatal and birth services during recent flooding. RESULTS: The theme 'Collaboration across the system creates adaptability in the response' reflects how collaboration and social relationships among providers, staff and the community have delineated boundaries for actions and decisions for services during floods. Floods were perceived as having a modest impact on health services. Knowing the boundaries on decision-making and having preparation and response plans let staff prepare and respond in a flexible yet stable way. The theme was derived from ideas of (1) seasonal floods as a minor strain on the system compared with persistent, system-wide organisational stresses the system already experiences, (2) the ability of the health services to adjust and adapt flood plans, (3) a shared purpose and working process during floods, (4) engagement at the local level to fulfil a professional duty to the community, and (5) creating relationships between health system levels and the community to enable flood response. CONCLUSION: The capacity to absorb and adapt to floods was seen among the public sector services. Strategies that enhance stability and flexibility may foster the capacity for health system resilience

Staying afloat: community perspectives on health system resilience in the management of pregnancy and childbirth care during floods in Cambodia.

INTRODUCTION: Resilient health systems have the capacity to continue providing health services to meet the community's diverse health needs following floods. This capacity is related to how the community manages its own health needs and the community and health system's joined capacities for resilience. Yet little is known about how community participation influences health systems resilience. The purpose of this study was to understand how community management of pregnancy and childbirth care during floods is contributing to the system's capacity to absorb, adapt or transform as viewed through a framework on health systems resilience. METHODS: Eight focus group discussions and 17 semi-structured interviews were conducted with community members and leaders who experienced pregnancy or childbirth during recent flooding in rural Cambodia. The data were analysed by thematic analysis and discussed in relation to the resilience framework. RESULTS: The theme 'Responsible for the status quo' reflected the community's responsibility to find ways to manage pregnancy and childbirth care, when neither the expectations of the health system nor the available benefits changed during floods. The theme was informed by notions on: i) developmental changes, the unpredictable nature of floods and limited support for managing care, ii) how information promoted by the public health system led to a limited decision-making space for pregnancy and childbirth care, iii) a desire for security during floods that outweighed mistrust in the public health system and iv) the limits to the coping strategies that the community prepared in case of flooding. CONCLUSIONS: The community mainly employed absorptive strategies to manage their care during floods, relieving the burden on the health system, yet restricted support and decision-making may risk their capacity. Further involvement in decision-making for care could help improve the health system's resilience by creating room for the community to adapt and transform when experiencing floods

Metabolism within the tumor microenvironment and its implication on cancer progression: an ongoing therapeutic target

Since reprogramming energy metabolism is considered a new hallmark of cancer, tumor metabolism is again in the spotlight of cancer research. Many studies have been carried out and many possible therapies have been developed in the last years. However, tumor cells are not alone. A series of extracellular components and stromal cells, such as endothelial cells, cancer-associated fibroblasts, tumor-associated macrophages and tumor-infiltrating T cells, surround tumor cells in the so-called tumor microenvironment. Metabolic features of these cells are being studied in deep in order to find relationships between metabolism within the tumor microenvironment and tumor progression. Moreover, it cannot be forgotten that tumor growth is able to modulate host metabolism and homeostasis, so that tumor microenvironment is not the whole story. Importantly, the metabolic switch in cancer is just a consequence of the flexibility and adaptability of metabolism and should not be surprising. Treatments of cancer patients with combined therapies including anti-tumor agents with those targeting stromal cell metabolism, anti-angiogenic drugs and/or immunotherapy are being developed as promising therapeutics.Mª Carmen Ocaña is recipient of a predoctoral FPU grant from the Spanish Ministry of Education, Culture and Sport. Supported by grants BIO2014-56092-R (MINECO and FEDER), P12-CTS-1507 (Andalusian Government and FEDER) and funds from group BIO-267 (Andalusian Government). The "CIBER de Enfermedades Raras" is an initiative from the ISCIII (Spain). The funders had no role in the study design, data collection and analysis, decision to publish or preparation of the manuscript

Health systems resilience in fragile and conflict-affected settings: a systematic scoping review

BackgroundHealth systems resilience (HSR) research is a rapidly expanding field, in which key concepts are discussed and theoretical frameworks are emerging with vibrant debate. Fragile and conflict-affected settings (FCAS) are contexts exposed to compounding stressors, for which resilience is an important characteristic. However, only limited evidence has been generated in such settings. We conducted a scoping review to: (a) identify the conceptual frameworks of HSR used in the analysis of shocks and stressors in FCAS; (b) describe the representation of different actors involved in health care governance and service provision in these settings; and (c) identify health systems operations as they relate to absorption, adaptation, and transformation in FCAS.MethodsWe used standard, extensive search methods. The search captured studies published between 2006 and January 2022. We included all peer reviewed and grey literature that adopted a HSR lens in the analysis of health responses to crises. Thematic analysis using both inductive and deductive approaches was conducted, adopting frameworks related to resilience characteristics identified by Kruk et al., and the resilience capacities described by Blanchet et al.ResultsThirty-seven studies met our inclusion criteria. The governance-centred, capacity-oriented framework for HSR emerged as the most frequently used lens of analysis to describe the health responses to conflict and chronic violence specifically. Most studies focused on public health systems' resilience analysis, while the private health sector is only examined in complementarity with the former. Communities are minimally represented, despite their widely acknowledged role in supporting HSR. The documentation of operations enacting HSR in FCAS is focused on absorption and adaptation, while transformation is seldom described. Absorptive, adaptive, and transformative interventions are described across seven different domains: safety and security, society, health system governance, stocks and supplies, built environment, health care workforce, and health care services.ConclusionsOur review findings suggest that the governance-centred framework can be useful to better understand HSR in FCAS. Future HSR research should document adaptive and transformative strategies that advance HSR, particularly in relation to actions intended to promote the safety and security of health systems, the built environment for health, and the adoption of a social justice lens

Transferability of Clinical Prediction Models for Early Trauma Care in a Swedish Setting

<div><a></a><div><a></a><a><div>Trauma is one of the top threats to population health globally. A substantial body of research has been devoted to the development of clinical prediction models to aid early decision making in trauma care. Often these models are applied outside the context in which they were originally developed. In contrast, very little research has focused on the effects on model performance of such transfers despite the fact that a potential loss in performance could have devastating consequences.</div></a></div><div><a><div><br></div></a></div> <div>We will use data from the Swedish trauma registry SweTrau to study the effects on model performance of transfers between different contexts within a single conceptually homogenous setting. Using logistic regression we will develop models for predicting all-cause mortality within 30 days of trauma in adult patients, focusing on systolic blood pressure, respiratory rate, and Glasgow coma scale as predictors. </div><div><br></div> <div>Four different sets of data sampled from SweTrau will be used to simulate transfer of models between high and low volume centres, metropolitan and non-metropolitan centres, multicentre and single centre data, and finally between individual centres. We will use measures of overall performance, clinical usefulness, discrimination, calibration, and recalibration to quantify the effects on performance of model transfers.</div><div><br></div> <div>We hope that our study will provide evidence to help clinicians and policy makers in deciding on whether it is appropriate to apply models developed in other contexts. For example, the results of this study may inform decisions on the development and implementation of models intended to be applied on a national or regional level, and ultimately help designing better trauma care and improve the outcomes of trauma patients.</div> </div><a></a

Health systems resilience in practice : a scoping review to identify strategies for building resilience

BACKGROUND: Research on health systems resilience has focused primarily on the theoretical development of the concept and its dimensions. There is an identified knowledge gap in the research on how to build resilience in health systems in practice and 'what works' in different contexts. The aim of this study is to identify practical strategies for building resilient health systems from the empirical research on health systems resilience.METHODS: A scoping review included empirical research on health systems resilience from peer-reviewed literature. The search in the electronic databases PubMed, Web of Science, Global Health was conducted during January to March 2021 for articles published in English between 2013 to February 2021. A total of 1771 articles were screened, and data was extracted from 22 articles. The articles included empirical, applied research on strategies for resilience, that observed or measured resilience during shocks or chronic stress through collection of primary data or analysis of secondary data, or if they were a review study of empirical research. A narrative summary was done by identifying action-oriented strategies, comparing them, and presenting them by main thematic areas.RESULTS: The results demonstrate examples of strategies used or recommended within nine identified thematic areas; use of community resources, governance and financing, leadership, surveillance, human resources, communication and collaboration, preparedness, organizational capacity and learning and finally health system strengthening.CONCLUSIONS: The findings emphasize the importance of improved governance and financing, empowered middle-level leadership, improved surveillance systems and strengthened human resources. A re-emphasized focus on health systems strengthening with better mainstreaming of health security and international health regulations are demonstrated in the results as a crucial strategy for building resilience. A lack of strategies for recovery and lessons learnt from crises are identified as gaps for resilience in future

The transfer of clinical prediction models for early trauma care had uncertain effects on mistriage

Objectives: This study aimed to assess how transfers of clinical prediction models for early trauma care between different care contexts within a single health system affected mistriage rates. Study Design and Setting: Patients aged 15 years or older, registered between 2011 and 2016 in the Swedish national trauma registry, SweTrau, were included. Three data set groups were created: high- and low-volume centers, metropolitan and nonmetropolitan centers, and multicenters and single centers. Clinical prediction models were developed using logistic regression in each data set group and transferred between data sets within groups. Model performance was evaluated using mistriage rate, undertriage rate, and overtriage rate. Multiple imputation using chained equations was used to handle missing data. Model performance was reported as medians with 95% confidence intervals (CIs). Results: A total of 26,965 patients were included. Changes in mistriage rates after transfer ranged from −0.25 (95% CI −0.21 to 0.04) to 0.29 (95% CI 0.13–0.39). Both overtriage and undertriage rates were affected. Conclusions: Transferring clinical prediction models for early trauma care is associated with substantial uncertainty in regards to the effect on model performance. Depending on the care context, model transfer led to either increased or decreased mistriage. Overtriage was more affected by model transfer than undertriage