Framework synthesis to inform the ideation and design of a paper-based health information system (PHISICC)

Background: Health information systems (HIS) are meant to support decision-making at all levels of the system, including frontline health workers. In field studies in Côte d’Ivoire, Mozambique and Nigeria, we observed health workers' interactions with the HIS and identified twelve decision-making components of HIS. The objective of this framework synthesis is to portray these components in HIS research, in order to inform the ideation of a paper-based HIS intervention (PHISICC). Methods: We searched studies in the Cochrane Central Register of Controlled Trials (CENTRAL), Embase, Epistemonikos, Medline, in-Process on the Ovid platform, OpenGrey, PDQ Evidence (“pretty darnd quick” Evidence), the World Health Organization (WHO) Global Health Library and included studies focussing on HIS interventions, data quality, information support tools and data use for decision-making in the context of the governmental health care sector. We assessed the methodological quality of studies using the Critical Appraisal Skills Programme tool. We synthesised the findings based on the decision-making components of HIS and thematic areas. Results: The search identified 6784 studies; 50 were included. Most of the 50 studies had quality concerns. All studies included at least one of the decision-making components: the most prominent were the technical aspects of ‘recording’ and ‘reporting’. Data use for decision-making was much less represented. Conclusion: HIS research focuses on the more technical aspects of HIS. Further research on HIS, given the strong push towards HIS digitalisation, should consider putting at the centre the human experience of decision-making and data use, in order to make HIS relevant for quality of care

Framework synthesis to inform the ideation and design of a paper-based health information system (PHISICC)

BACKGROUND: Health information systems (HIS) are meant to support decision-making at all levels of the system, including frontline health workers. In field studies in Cote d'Ivoire, Mozambique and Nigeria, we observed health workers' interactions with the HIS and identified twelve decision-making components of HIS. The objective of this framework synthesis is to portray these components in HIS research, in order to inform the ideation of a paper-based HIS intervention (PHISICC). METHODS: We searched studies in the Cochrane Central Register of Controlled Trials (CENTRAL), Embase, Epistemonikos, Medline, in-Process on the Ovid platform, OpenGrey, PDQ Evidence ("pretty darnd quick" Evidence), the World Health Organization (WHO) Global Health Library and included studies focussing on HIS interventions, data quality, information support tools and data use for decision-making in the context of the governmental health care sector. We assessed the methodological quality of studies using the Critical Appraisal Skills Programme tool. We synthesised the findings based on the decision-making components of HIS and thematic areas. RESULTS: The search identified 6784 studies; 50 were included. Most of the 50 studies had quality concerns. All studies included at least one of the decision-making components: the most prominent were the technical aspects of 'recording' and 'reporting'. Data use for decision-making was much less represented. CONCLUSION: HIS research focuses on the more technical aspects of HIS. Further research on HIS, given the strong push towards HIS digitalisation, should consider putting at the centre the human experience of decision-making and data use, in order to make HIS relevant for quality of care

Can Action Research Strengthen District Health Management and Improve Health Workforce Performance? A Research Protocol.

The single biggest barrier for countries in sub-Saharan Africa (SSA) to scale up the necessary health services for addressing the three health-related Millennium Development Goals and achieving Universal Health Coverage is the lack of an adequate and well-performing health workforce. This deficit needs to be addressed both by training more new health personnel and by improving the performance of the existing and future health workforce. However, efforts have mostly been focused on training new staff and less on improving the performance of the existing health workforce. The purpose of this paper is to disseminate the protocol for the PERFORM project and reflect on the key challenges encountered during the development of this methodology and how they are being overcome. The overall aim of the PERFORM project is to identify ways of strengthening district management in order to address health workforce inadequacies by improving health workforce performance in SSA. The study will take place in three districts each in Ghana, Tanzania and Uganda using an action research approach. With the support of the country research teams, the district health management teams (DHMTs) will lead on planning, implementation, observation, reflection and redefinition of the activities in the study. Taking into account the national and local human resource (HR) and health systems (HS) policies and practices already in place, 'bundles' of HR/HS strategies that are feasible within the context and affordable within the districts' budget will be developed by the DHMTs to strengthen priority areas of health workforce performance. A comparative analysis of the findings from the three districts in each country will add new knowledge on the effects of these HR/HS bundles on DHMT management and workforce performance and the impact of an action research approach on improving the effectiveness of the DHMTs in implementing these interventions. Different challenges were faced during the development of the methodology. These include the changing context in the study districts, competing with other projects and duties for the time of district managers, complexity of the study design, maintaining the anonymity and confidentiality of study participants as well as how to record the processes during the study. We also discuss how these challenges are being addressed. The dissemination of this research protocol is intended to generate interest in the PERFORM project and also stimulate discussion on the use of action research in complex studies such as this on strengthening district health management to improve health workforce performance

The effects of radiofrequency electromagnetic fields exposure on human self-reported symptoms: a protocol for a systematic review of human experimental studies

BACKGROUND: The technological applications of radiofrequency electromagnetic fields (RF-EMF) have been steadily increasing since the 1950s across multiple sectors exposing large proportions of the population. This fact has raised concerns related to the potential consequences to people's health. The World Health Organization (WHO) is assessing the potential health effects of exposure to RF-EMF and has carried out an international survey amongst experts, who have identified six priority topics to be further addressed through systematic reviews, whereof the effects on symptoms is one of them. We report here the systematic review protocol of experimental studies in humans assessing the effects of RF-EMF on symptoms. OBJECTIVE: Our objectives are to assess the effects of exposure to electromagnetic fields (compared to no or lower exposure levels) on symptoms in human subjects. We will also assess the accuracy of perception of presence of exposure in volunteers with and without idiopathic environmental intolerance attributed to electromagnetic fields (IEI-EMF). ELIGIBILITY CRITERIA: We will search relevant literature sources (e.g. the Web of Science, Medline, Embase, Epistemonikos) for randomized trials (comparing at least two arms) and randomised crossover trials of RF-EMF exposure that have assessed the effects on symptoms. We will also include studies that have measured the accuracy of the perception of the presence or absence of exposure. We will include studies in any language. STUDY APPRAISAL AND SYNTHESIS: Studies will be assessed against inclusion criteria by two independent reviewers. Data on study characteristics, participants, exposure, comparators and effects will be extracted using a specific template for this review, by two independent reviewers. Discrepancies will be solved by consensus. Risk of bias (ROB) will be assessed using the ROB Rating Tool for Human and Animal Studies and the level of confidence in the evidence of the exposure-outcome relations will be assessed using the GRADE approach. For the perception studies, we will use adapted versions of the ROB tool and GRADE assessment. Where appropriate, data will be combined using meta-analytical techniques

Cost-effectiveness analysis of an intervention project engaging traditional and religious leaders to improve uptake of childhood immunization in southern Nigeria

Vaccination is a cost-effective public health intervention, yet evidence abounds that vaccination uptake is still poor in many low- and middle-income countries. Traditional and Religious Leaders play a substantial role in improving the uptake of health services such as immunization. However, there is paucity of evidence on the cost-effectiveness of using such strategies. This study aimed to assess the cost-effectiveness of using a multi-faceted intervention that included traditional and religious leaders for community engagement to improve uptake of routine immunisation services in communities in Cross River State, Southern Nigeria. The target population for the intervention was traditional and religious leaders in randomly selected communities in Cross River State. The impact of the intervention on the uptake of routine vaccination among children 0 to 23 months was assessed using a cluster randomized trials. Outcome assessments were performed at the end of the project (36 months).The cost of the intervention was obtained from the accounting records for expenditures incurred in the course of implementing the intervention. Costs were assessed from the health provider perspective. The cost-effectiveness analysis showed that the incremental cost of the initial implementation of the intervention was US$19,357and that the incremental effect was 323 measles cases averted, resulting in an incremental cost-effectiveness ratio (ICER) of US$60/measles case averted. However, for subsequent scale-up of the interventions to new areas not requiring a repeat expenditure of some of the initial capital expenditure the ICER was estimated to be US$34 per measles case averted. Involving the traditional and religious leaders in vaccination is a cost-effective strategy for improving the uptake of childhood routine vaccinations

Effects of engaging communities in decision-making and action through traditional and religious leaders on vaccination coverage in Cross River State, Nigeria: a cluster-randomised control trial

BACKGROUND: Vaccination coverage levels fall short of the Global Vaccine and Action Plan 90% target in low- and middle- income countries (LMICs). Having identified traditional and religious leaders (TRLs) as potential public health change agents, this study aimed at assessing the effect of training them to support routine immunisation for the purpose of improving uptake of childhood vaccines in Cross River State, Nigeria. METHODS: A cluster-randomised controlled study was conducted between 2016 and 2019. Of the 18 Local Government Areas (LGA) in Cross River State, eight (four urban and four rural LGAs) were randomized into the intervention and control study arms. A multi-component intervention involving the training of traditional and religious leaders was implemented in the four intervention LGAs. Baseline, midline and endline surveys collected information on children aged 0-23 months. The effect of the intervention on outcomes including the proportion fully up-to-date with vaccination, timely vaccination for pentavalent and measles vaccines, and pentavalent 1-3 dropout rates were estimated using logistic regression models using random effects to account for the clustered data. RESULTS: A total of 2598 children at baseline, 2570 at midline, and 2550 at endline were included. The intervention was effective in increasing the proportion with at least one vaccine (OR 12.13 95% CI 6.03-24.41p<0.001). However, there was no evidence of an impact on the proportion of children up-to-date with vaccination (p = 0.69). It was effective in improving timeliness of Pentavalent 3 (OR 1.55; 95% CI: 1.14, 2.12; p = 0.005) and Measles (OR 2.81; 96% CI: 1.93-4.1; p<0.001) vaccination. The odds of completing Pentavalent vaccination increased (OR = 1.66 95% CI: 1.08,2.55). CONCLUSION: Informal training to enhance the traditional and religious leaders' knowledge of vaccination and their leadership role can empower them to be good influencers for childhood vaccination. They constitute untapped resources in the community to boost routine immunisation. Pan African Clinical Trial Registry (PACTR) PACTR202008784222254

The effects of radiofrequency electromagnetic fields exposure on tinnitus, migraine and non-specific symptoms in the general and working population: a protocol for a systematic review on human observational studies

BACKGROUND: Applications emitting radiofrequency electromagnetic fields (RF-EMF; 100 kHz to 300 GHz) are widely used for communication (e.g. mobile phones), in medicine (diathermy) and in industry (RF heaters). Concern has been raised that RF-EMF exposure affects health related quality of life, because a part of the population reports to experience a variety of symptoms related to low exposure levels below regulatory limits. OBJECTIVES: To systematically review the effects of longer-term or repeated local and whole human body RF-EMF exposure on the occurrence of symptoms evaluating migraine, tinnitus, headaches, sleep disturbances and composite symptom scores as primary outcomes. METHODS: We will follow the WHO handbook for guideline development. For the development of the systematic review protocol we considered handbook for conducting systematic reviews for health effects evaluations from the National Toxicology Program-Office of Health Assessment and Translation (NTP-OHAT) and COSTER (Recommendations for the conduct of systematic reviews in toxicology and environmental health research). ELIGIBILITY CRITERIA: Peer-reviewed epidemiological studies in the general population or workers aiming to investigate the association between local or whole-body RF-EMF exposure for at least one week and symptoms are eligible for inclusion. Only cohort, case-control and panel studies will be included. INFORMATION SOURCES: We will search the scientific literature databases Medline, Web of Science, PsycInfo, Cochrane Library, Epistemonikos and Embase, using a predefined search strategy. This search will be supplemented by a search in the EMF-Portal and checks of reference lists of relevant papers and reviews. STUDY APPRAISAL AND SYNTHESIS METHOD: Data from included papers will be extracted according to predefined forms. Findings will be summarized in tables, graphical displays and in a narrative synthesis of the available evidence, complemented with meta-analyses. We will separately review effects of local, far field and occupational exposure. RISK OF BIAS: The internal validity of included studies will be assessed using the NTP-OHAT Risk of Bias Rating Tool for Human and Animal Studies, elaborated to observational RF-EMF studies. EVIDENCE APPRAISAL: To rate certainty of the evidence, we will use the OHAT GRADE-based approach for epidemiological studies. FRAMEWORK AND FUNDING: This protocol concerns one of the ten different systematic reviews considered in a larger systematic review of the World Health Organization to assess potential health effects of exposure to RF-EMF in the general and working population. REGISTRATION: PROSPERO CRD42021239432

Better Guidance Is Welcome, but without Blinders

David Peters and Sara Bennett provide a critical perspective on a three-part series on health systems guidance that examines how evidence should be used to strengthen health systems and improve the delivery of global health interventions

Using and improving the PHISICC paper-based tools in the health facility laboratories: examples of Human Centered Design taking systems thinking into practice, in Côte d'Ivoire and Nigeria

BackgroundHealth workers in low- and middle-income countries are increasingly demanded to collect more and more data to report them to higher levels of the health information system (HIS), in detriment of useful data for clinical and public health decision-making, potentially compromising the quality of their health care provison. In order to support health workers' decision-making, we engaged with partners in Côte d'Ivoire, Mozambique and Nigeria in a research project to conceive, design, produce, implement and test paper-based health information tools: the PHISICC tools. Our aim was to understand the use of PHISICC tools by health workers and to improve them based on their feedback.MethodsThe design Health Facility Laboratories (HF Labs) in Côte d'Ivoire and in Nigeria were set up after months of use of PHISICC tools. Activities were structured in three phases or 'sprints' of co-creative research. We used a transdisciplinary approach, including anthropology and Human Centered Design (HCD), observations, shadowing, structured interviews and co-creation.ResultsHealth workers appreciated the standardization of the tools across different health care areas, with a common visual language that optimized use. Several design issues were raised, in terms of formats and contents. They strongly appreciated how the PHISICC registers guided their clinical decision-making and how it facilitated tallying and counting for monthly reporting. However, adherence to new procedures was not universal. The co-creation sessions resulted in modifications to the PHISICC tools of out-patient care and postnatal care.DiscussionAlthough health systems and systemic thinking allowed the teams to embrace complexity, it was the HCD approach that actually produced a shift in researchers' mind-set: from HIS as data management tools to HIS as quality of care instruments. HCD allowed navigating the complexity of health systems interventions due to its capacity to operate change: it not only allowed us to understand how the PHISICC tools were used but also how to further improve them. In the absence of (or even with) an analytical health systems framework, HCD approaches can work in real-life situations for the ideation, testing and implementation of interventions to improve health systems and health status outcomes

District Health Managers' Perceptions of Supervision in Malawi and Tanzania.

Mid-level cadres are being used to address human resource shortages in many African contexts, but insufficient and ineffective human resource management is compromising their performance. Supervision plays a key role in performance and motivation, but is frequently characterised by periodic inspection and control, rather than support and feedback to improve performance. This paper explores the perceptions of district health management teams in Tanzania and Malawi on their role as supervisors and on the challenges to effective supervision at the district level. This qualitative study took place as part of a broader project, "Health Systems Strengthening for Equity: The Power and Potential of Mid-Level Providers". Semi-structured interviews were conducted with 20 district health management team personnel in Malawi and 37 council health team members in Tanzania. The interviews covered a range of human resource management issues, including supervision and performance assessment, staff job descriptions and roles, motivation and working conditions. Participants displayed varying attitudes to the nature and purpose of the supervision process. Much of the discourse in Malawi centred on inspection and control, while interviewees in Tanzania were more likely to articulate a paradigm characterised by support and improvement. In both countries, facility level performance metrics dominated. The lack of competency-based indicators or clear standards to assess individual health worker performance were considered problematic. Shortages of staff, at both district and facility level, were described as a major impediment to carrying out regular supervisory visits. Other challenges included conflicting and multiple responsibilities of district health team staff and financial constraints. Supervision is a central component of effective human resource management. Policy level attention is crucial to ensure a systematic, structured process that is based on common understandings of the role and purpose of supervision. This is particularly important in a context where the majority of staff are mid-level cadres for whom regulation and guidelines may not be as formalised or well-developed as for traditional cadres, such as registered nurses and medical doctors. Supervision needs to be adequately resourced and supported in order to improve performance and retention at the district level