Fragmentation of payment systems: an in-depth qualitative study of stakeholders' experiences with the neonatal intensive care payment system in Iran.

BACKGROUND: Iran's fee-for-service (FFS) payment model in neonatal intensive care units (NICUs) is contentious due to the involvement of multiple stakeholders with differing interests, leading to increased costs, fragmentation, and reduced quality of care. This study explores the experiences and challenges of stakeholders with the NICU payment system and considers alternative payment methods. METHOD: A qualitative research approach was used, involving key informant interviews with stakeholders at various levels of the health system. Data were collected between March 2022 to September 2023 using a purposive sampling method with a snowball strategy. The transcribed data were analyzed using an inductive thematic approach in MAXQDA, with themes and sub-themes emerged and assessed by two independent coders. Four trustworthiness criteria were applied to ensure the quality of the results. RESULTS: The study involved 23 participants with diverse NICU payment backgrounds, identifying issues related to service accessibility, rising costs, neonatologists' income, and service quality. Stakeholders held differing views on the best payment model: health insurance executives favored a prospective payment method, faculty members favored supported modified FFS or per diem, and neonatal specialists expressed concerns about low tariffs and delayed payments. CONCLUSION: Iran's NICU payment system is unsatisfactory and requires urgent reform. Although stakeholders disagree on the best approach, reforms must be evidence-based and collaborative, addressing structural and cultural issues within the health system. The identification of an optimal payment system is essential for supporting neonatal care, benefiting newborns, families, society, and the broader health system.

Contextualizing family planning messages for the BornFyne-PNMS digital platform in Cameroon: a community-based approach.

BACKGROUND: Family planning (FP) is crucial for reducing maternal and infant mortality and morbidity, particularly through the prevention of unsafe abortions resulting from unwanted pregnancies. Despite Cameroon's commitment to increasing the adoption of modern FP strategies, rural and poor populations still exhibit low demand due to limited access to healthcare services. This study documents the approach in developing family planning messages for the BornFyne prenatal management system as a platform to improve family planning awareness and enhance uptake. METHOD: This is a mixed-methods study that employed the Health Belief Model (HBM). The study included a cross-sectional survey and focus group discussions in four districts of Cameroon. The survey explored household perspectives of FP and the use of mobile phone. Focus group discussions involved women, men, and community health workers to gain in-depth insights. Thematic analysis using themes from the HBM guided the analysis, focusing on perceived benefits, barriers, and cues to action. RESULTS: The survey included 3,288 responses. Thematic analysis of focus group discussions highlighted knowledge gaps and areas requiring additional information. Identified gaps informed the development of targeted FP messages aligned with BornFyne objectives and the Health Belief Model. Results revealed that most respondents recognized the benefits of FP but faced knowledge barriers related to side effects, cultural influences, and communication challenges between partners. Focus group discussions further highlighted the need for education targeting both men and women, dispelling misconceptions, and addressing adolescent and youths' ignorance. The study emphasized the importance of tailored messaging for specific demographic groups and culture. CONCLUSION: Developing effective FP intervention messages requires a nuanced understanding of community perspectives. The BornFyne-PNMS family planning feature, informed by the Health Belief Model, addresses knowledge gaps by delivering educational messages in local dialects via mobile phones. The study's findings underscore the importance of community-based approaches to contextualizing and developing FP content targeting specific populations to generate tailored messages to promote awareness, acceptance, and informed decision-making. The contextualized and validated messages are uploaded into the BornFyne-family planning feature.

Utilisation of mobile phone interventions to improve the delivery of maternal health services in sub-Saharan Africa: A scoping review protocol.

INTRODUCTION: There has been significant progress in maternal health outcomes in the sub-Saharan African region since the early 1990s, in part due to digital and mobile health interventions. However, critical gaps and disparities remain. Mobile phones in particular have potential to reach underserved, hard-to-reach populations with underdeveloped infrastructure. In spite of the opportunities for mobile phones to address maternal mortality in the region, there is no extensive mapping of the available literature on mobile phone interventions that aim to improve access of maternal care in sub-Saharan Africa. The proposed scoping review aims to map literature on the nature and extent of mobile phones interventions designed to improve maternal care health services in the region. METHODS: Conduct of this scoping review will be guided by the Joanna Briggs Institute approach. Literature searches will be conducted in multiple electronic databases, including MEDLINE, Embase, CINAHL, APA PsycInfo, Cochrane Central Register of Controlled Trials, Global Health, African Index Medicus, Web of Science, and Applied Social Sciences Index & Abstracts. Grey literature will also be identified. Keyword searches will be used to identify articles. Two reviewers will independently screen eligible titles, abstracts and full articles with a third reviewer to help resolve any disputes. We will extract data on general study characteristics, population characteristics, concept, context, intervention details, study results, gaps and recommendations. DISCUSSION: Understanding use of mobile phones among underserved, hard-to-reach populations with underdeveloped infrastructure to address maternal mortality in developing countries is very critical to informing health systems on potential effective strategies. This review will complement the evidence base on utilisation of mobile phone interventions to improve the delivery of maternal health services in sub-Saharan Africa.

Adjustments in purchasing arrangements to support the COVID-19 health sector response: evidence from eight middle-income countries.

The COVID-19 pandemic has triggered several changes in countries' health purchasing arrangements to accompany the adjustments in service delivery in order to meet the urgent and additional demands for COVID-19-related services. However, evidence on how these adjustments have played out in low- and middle-income countries is scarce. This paper provides a synthesis of a multi-country study of the adjustments in purchasing arrangements for the COVID-19 health sector response in eight middle-income countries (Armenia, Cameroon, Ghana, Kenya, Nigeria, Philippines, Romania and Ukraine). We use secondary data assembled by country teams, as well as applied thematic analysis to examine the adjustments made to funding arrangements, benefits packages, provider payments, contracting, information management systems and governance arrangements as well as related implementation challenges. Our findings show that all countries in the study adjusted their health purchasing arrangements to varying degrees. While the majority of countries expanded their benefit packages and several adjusted payment methods to provide selected COVID-19 services, only half could provide these services free of charge. Many countries also streamlined their processes for contracting and accrediting health providers, thereby reducing administrative hurdles. In conclusion, it was important for the countries to adjust their health purchasing arrangements so that they could adequately respond to the COVID-19 pandemic, but in some countries financing challenges resulted in issues with equity and access. However, it is uncertain whether these adjustments can and will be sustained over time, even where they have potential to contribute to making purchasing more strategic to improve efficiency, quality and equitable access in the long run.

Community participation for reproductive, maternal, newborn and child health: insights from the design and implementation of the BornFyne-prenatal management system digital platform in Cameroon.

Introduction: Across communities in low-middle income countries, digital health is currently revolutionizing the delivery of health services, particularly in the field of reproductive, maternal, newborn, and child health (RMNCH) services. While studies have shown the effectiveness of mHealth in delivering RMNCH services, there is little information about factors that enhance mHealth services utilization in low-cost settings including stakeholders' level of influence on the implementation of digital health intervention in sub-Saharan Africa. This paper seeks to describe important lessons on the levels of stakeholders' direct or indirect influence on the design and implementation of the BornFyne-PNMS digital health platform to support RMNCH services. Methods: A participatory research (PR) design approach was employed to explore stakeholders' perspectives of a new initiative, through direct engagement of local priorities and perspectives. The process of introducing the digital application called the BornFyne-PNMS for district health delivery system and the community, and integrating it within the district health delivery system was guided by research-to-action, consistent with the PR approach. To explore stakeholders' perspectives through a PR approach, we conducted a series of stakeholder meetings fashioned after focus group discussions. Results: Issues around male involvement in the program, sensitization and equity concerns arose. Emergent challenges and proposed strategies for implementation from diverse stakeholders evidently enriched the design and implementation process of the project intervention. Stakeholder meetings informed the addition of variables on the mobile application that were otherwise initially omitted, which will further enhance the RMNCH electronic data collection for health information systems strengthening in Cameroon. Discussion: This study charts a direction that is critical in digital health delivery of RMNCH in a rural and low-income community and describes the important iterative stakeholder input throughout the study. The strategy of stakeholders' involvement in the BornFyne PNMS implementation charts a direction for ownership and sustainability in the strengthening of Cameroon's health information system.

An in-depth qualitative study of health care providers' experiences of performance-based financing program as a nation-wide adopted policy in Cameroon: A principal-agent perspective.

OBJECTIVES: The study applies the principal-agent approach to explore providers' experiences before and after the introduction of performance-based financing (PBF) in Cameroon, challenges and facilitators in the implementation process, and mechanisms in place to ensure sustainability. METHODS: The study was an in-depth qualitative study whose goal was to provide multiple descriptions of experiences and insights from a principal-agent analysis perspective. Purposive sampling was used to identify the key characteristics of the participants relevant to the study. A snowballing technique was used to further identify eligible participants. Only healthcare providers who were exposed to the previous system and could reflect on and provide meaningful data that captured the everyday experiences before and after the implementation of PBF were included. Data were collected from three districts in the Southwest region of Cameroon from May 2021 to August 2021. Data were transcribed and analyzed using MaxQDA. RESULTS: A total of 17 interviews and 3 focus group discussions (24 participants) were conducted with healthcare providers and key stakeholders involved in PBF. The respondents described a range of changes that they had experienced since the introduction of PBF. Each of these changes was categorized as either positive or negative. Positive changes were framed into 14 dominant categories: motivation, negotiations, innovation, resource allocation, autonomy, decentralization, transparency, improved quality of care, separation of function, performance, equity considerations, opportunity to recruit, participation in decision-making, and improved access to and utilization of maternal health services. The main challenges (negative experiences) reported were framed into nine categories: management of change, retention issues, conflict of interest, poor understanding of the PBF concept, resistance to change, verification challenges, delays in payment of PBF incentives, data entry and documentation, and challenges in meeting the equity considerations of the poor and vulnerable. Despite the challenges, providers preferred the decentralized approach to the centralized system. CONCLUSION: PBF is a national strategy for achieving universal health coverage in Cameroon, and the experiences of providers provide a vital guide to refine national policy. The introduction of PBF has provided positive changes to providers' quality of care when compared to the previous system. Addressing the delays in PBF payments will help to overcome the challenges to implementation and provide opportunities for health facilities to be more efficient and improve their performance. Despite the limitations of delay in payment, PBF helps to align the incentives of the health workers (agent) with those of the Ministry of Health (principal).

A scoping review establishes need for consensus guidance on reporting health equity in observational studies.

OBJECTIVES: To evaluate the support from the available guidance on reporting of health equity in research for our candidate items and to identify additional items for the Strengthening Reporting of Observational studies in Epidemiology-Equity extension. STUDY DESIGN AND SETTING: We conducted a scoping review by searching Embase, MEDLINE, CINAHL, Cochrane Methodology Register, LILACS, and Caribbean Center on Health Sciences Information up to January 2022. We also searched reference lists and gray literature for additional resources. We included guidance and assessments (hereafter termed "resources") related to conduct and/or reporting for any type of health research with or about people experiencing health inequity. RESULTS: We included 34 resources, which supported one or more candidate items or contributed to new items about health equity reporting in observational research. Each candidate item was supported by a median of six (range: 1-15) resources. In addition, 12 resources suggested 13 new items, such as "report the background of investigators". CONCLUSION: Existing resources for reporting health equity in observational studies aligned with our interim checklist of candidate items. We also identified additional items that will be considered in the development of a consensus-based and evidence-based guideline for reporting health equity in observational studies.

A systematic review of the effect of performance-based financing interventions on out-of-pocket expenses to improve access to, and the utilization of, maternal health services across health sectors in sub-Saharan Africa.

Background: Performance-based financing (PBF) assumes that subsidizing user fees for maternal health services to reduce out-of-pocket expenses will expand coverage and reduce inequities in access to maternal health services. It is usually associated with process changes, and the idea that increasing a facility's resources from PBF interventions can improve the availability of equipment, drugs, and medical supplies at the facility, has an indirect effect on out-of-pocket expenses. Assessment of complex interventions such as PBF requires consideration of specific underlying assumption or theories of change. Such assessment will allow a better and broader understanding of the system's strengths and weaknesses, where the gaps lie, whether the theory of change is sound, and will inform policy design and implementation. Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) checklist, we performed a systematic review and a critical appraisal of selected studies using the risk-of-bias criteria developed by the Cochrane Effective Practice and Organisation of Care. We used the Grading of Recommendation and Evaluation, Development and Assessment framework for assessing the overall strength of the evidence. Results: After the abstract screening (n = 9873), we deemed 302 as relevant for full-text screening and assessed 85 studies for review eligibility. Finally, we included 17 studies in the review. We could not conduct a meta-analysis, so we report a narrative synthesis. As an add-on to an existing payment mechanism, PBF may facilitate the removal of operational barriers to enhance utilization of certain maternal health services in some contexts, especially in public facilities. Conclusions: PBF strategies may potentially decrease out-of-pocket expenses for specific maternal health services, especially in settings that have already instituted some form of user fee exemption policies on maternal health services. The implementation of PBF can be considered a potential access instrument in reducing out-of-pocket expenses to stimulate demand for maternal services. However, the implementation approaches employed will determine utilization, taking into consideration existing equitable and inequitable access characteristics which vary by context. Registration: PROSPERO CRD42020222893.

Improving social justice in observational studies: protocol for the development of a global and Indigenous STROBE-equity reporting guideline.

BACKGROUND: Addressing persistent and pervasive health inequities is a global moral imperative, which has been highlighted and magnified by the societal and health impacts of the COVID-19 pandemic. Observational studies can aid our understanding of the impact of health and structural oppression based on the intersection of gender, race, ethnicity, age and other factors, as they frequently collect this data. However, the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline, does not provide guidance related to reporting of health equity. The goal of this project is to develop a STROBE-Equity reporting guideline extension. METHODS: We assembled a diverse team across multiple domains, including gender, age, ethnicity, Indigenous background, disciplines, geographies, lived experience of health inequity and decision-making organizations. Using an inclusive, integrated knowledge translation approach, we will implement a five-phase plan which will include: (1) assessing the reporting of health equity in published observational studies, (2) seeking wide international feedback on items to improve reporting of health equity, (3) establishing consensus amongst knowledge users and researchers, (4) evaluating in partnership with Indigenous contributors the relevance to Indigenous peoples who have globally experienced the oppressive legacy of colonization, and (5) widely disseminating and seeking endorsement from relevant knowledge users. We will seek input from external collaborators using social media, mailing lists and other communication channels. DISCUSSION: Achieving global imperatives such as the Sustainable Development Goals (e.g., SDG 10 Reduced inequalities, SDG 3 Good health and wellbeing) requires advancing health equity in research. The implementation of the STROBE-Equity guidelines will enable a better awareness and understanding of health inequities through better reporting. We will broadly disseminate the reporting guideline with tools to enable adoption and use by journal editors, authors, and funding agencies, using diverse strategies tailored to specific audiences.

Examining the Implementation of the Performance-Based Financing Equity Strategy in Improving Access and Utilization of Maternal Health Services in Cameroon: A Qualitative Study.

Performance-based financing (PBF)-a supply-side strategy that incentivizes health providers based on predefined quality and quantity criteria-introduced an innovative approach to reaching the poor by means of using PBF equity instruments. These PBF equity instruments include paying providers more to reach out to poor women, selecting services used by the poor, subsidizing user fees to reduce out-of-pocket expenses, and adding complementary demand-side intervention. Before the implementation of the PBF equity instrument in Cameroon, there were few initiatives/schemes to enable the poor to access maternal health services. Moreover, there is a significant research gap on how the equity elements are defined and implemented across contexts. This study aims to understand (i) how health facilities define and classify the poor and vulnerable in the context of PBF, (ii) how the equity elements are implemented at the community and facility levels, and (iii) the potential impact on access to and the use of maternal health services at the facility level and challenges in the implementation process. We used key informant interviews and focus group discussions (FGDs) based on a grounded theory approach to gain an understanding of the social processes and experiences. Data were collected from three districts in the Southwest region of Cameroon from April 2021 to August 2021. Data were transcribed and analyzed using MaxQDA. The thematic analysis approach/technique was used to analyze data. Key informant interviews and focus groups were conducted with 79 participants, including 28 health professionals and service administrators, 27 pregnant women, and 24 community health workers in three districts. Health facilities employed various subjective approaches to assess and define poor and vulnerable (PAV) persons. Home visits were reported to have an impact in reaching the poor and vulnerable to improve access to maternal services. Meanwhile, a delay in the payment of PBF incentives was reported to be the main challenge that had a negative relationship with the consistent provision of care to the poor and vulnerable, especially in private health facilities. The theory generated from our findings suggests that the impact of the PBF equity elements specific to maternal health depends on (i) a shared understanding of the definition of PAV among different stakeholders, including providers and users, as well as how the PAV is operationalized (structure), and (ii) the appropriate and timely payment of incentives to health facilities and health providers.

The effect of performance-based financing interventions on out-of-pocket expenses intended to improve access to and utilization of maternal health services in sub-Saharan Africa: protocol for a systematic review and meta-analysis.

BACKGROUND: Out-of-pocket expenses have been reported as a major barrier to accessing antenatal care and skilled birth delivery in most of sub-Saharan Africa. Performance-based financing (PBF) is one of several strategies introduced in lower- and middle-income countries to strengthen a weak health system. This review aims to synthesize evidence on the effectiveness of PBF interventions implemented with the objective of reducing out-of-pocket expenses and improving access to and utilization of ANC and skilled birth delivery and family planning in sub-Saharan Africa. It will consider evidence across health sectors and identify gaps in the evidence. METHODS AND ANALYSIS: This protocol is reported according to Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guideline. The systematic review will apply a three-step strategy to search five databases (CINAHL, PubMed, Ovid Medline, EMBASE, Cochrane.) and grey literature with the help of a librarian. Two independent reviewers will conduct screening to determine eligibility and critical appraisal of selected studies using the risk of bias criteria developed by the Cochrane EPOC Group and the New Castle Ottawa Scale for observational studies. The certainty of evidence for the outcomes will be assessed using "Grades of Recommendation, Assessment, Development, and Evaluation" (GRADE) approach. This review will consider experimental and quasi-experimental study designs and observational studies. Studies published in English and French language(s) will be included. Studies published since the introduction of PBF in sub-Saharan Africa will be included. Data will be collected on each item that contributes to out-of-pocket expenses. This review will adopt the Multiple Dimensions of Access Framework to organize the findings. DISCUSSION: This systematic review will support evidence-informed data for the performance-based financing community and government by identifying, describing, and assessing the impact of performance-based financing interventions on out-of-pocket expenses in promoting access and utilization of ANC, skilled birth delivery, and family planning across health sectors. SYSTEMATIC REVIEW REGISTRATION: This review has been registered with PROSPERO, Registration number CRD42020222893 .

Guidance relevant to the reporting of health equity in observational research: a scoping review protocol.

INTRODUCTION: Health inequities are defined as unfair and avoidable differences in health between groups within a population. Most health research is conducted through observational studies, which are able to offer real-world insights about etiology, healthcare policy/programme effectiveness and the impacts of socioeconomic factors. However, most published reports of observational studies do not address how their findings relate to health equity. Our team seeks to develop equity-relevant reporting guidance as an extension of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. This scoping review will inform the development of candidate items for the STROBE-Equity extension. We will operationalise equity-seeking populations using the PROGRESS-Plus framework of sociodemographic factors. As part of a parallel stream of the STROBE-Equity project, the relevance of candidate guideline items to Indigenous research will be led by Indigenous coinvestigators on the team. METHODS AND ANALYSIS: We will follow the Joanna Briggs Institute method for conducting scoping reviews. We will evaluate the extent to which the identified guidance supports or refutes our preliminary candidate items for reporting equity in observational studies. These candidate items were developed based on items from equity-reporting guidelines for randomised trials and systematic reviews, developed by members of this team. We will consult with our knowledge users, patients/public partners and Indigenous research steering committee to invite suggestions for relevant guidance documents and interpretation of findings. If the identified guidance suggests the need for additional candidate items, they will be developed through inductive thematic analysis. ETHICS AND DISSEMINATION: We will follow a principled approach that promotes ethical codevelopment with our community partners, based on principles of cultural safety, authentic partnerships, addressing colonial structures in knowledge production and the shared ownership, interpretation, and dissemination of research. All products of this research will be published as open access.

Hospital and related resource costs associated with antimicrobial-resistant infections in Canada, 2019.

Background: Antimicrobial resistance (AMR) occurs when microorganisms become resistant to treatment by standard, or first-line, antibiotic drugs. These infections create an enormous burden on society due to longer hospital stays and increased morbidity and mortality, resulting in increased medical costs and foregone resources. The objective of this paper is to estimate the hospital costs associated with two of the most significant antibiotic-resistant organisms: methicillin-resistant Staphylococcus aureus (MRSA) and Clostridioides difficile (C. difficile), for Canada, for the year 2019, as well as the value of other resource use attributed to the lost production due to disability and premature mortality. Methods: The Discharge Abstract Database was employed for the analysis using a two-step process: first, the number of cases for each diagnosis was estimated; and then an average cost per case was derived, which was used to multiply the number of cases to obtain the total costs. Costs were derived using a regression model, accounting for demographic and other important confounding variables. Results: There were a total of 16,070 and 9,889 cases of C. difficile infections and MRSA infections, respectively, in Canada in 2019, resulting in an estimated 1,743 premature deaths. The majority of cases occurred in the older age groups. The hospital costs attributable to these infections were over $125 million, while the indirect resource costs were between $18.8 and $146.9 million. Conclusion: Quantifying the outcomes associated with antimicrobial-resistant infections provides valuable information for policymakers and is an essential first step in understanding the total economic impacts of AMR.

Scoping review protocol to understand the conceptualisation, implementation and practices of health promotion within the context of primary healthcare in Africa.

INTRODUCTION: The ongoing COVID-19 pandemic has highlighted the importance of health promotion in empowering and sustaining communities, as well as the need to build resilient health systems and work collectively with other sectors to protect and promote health. The WHO has mainstreamed health promotion in the Global health agenda. However, the definition and practices of health promotion in Africa are not well understood and documented, with often, an interchangeable use of the concept of health promotion and health prevention. This scoping review is to explore how health promotion is defined and practised in Africa and identify gaps in its implementation within the framework of the Ottawa Charter. METHODS AND ANALYSIS: The scoping review will employ the approach described by Arksey and O'Malley in 2005. The approach consists of five stages: (1) formulating the research questions, (2) identifying relevant studies, (3) selecting eligible studies, (4) charting the data and (5) collating, summarising and reporting the results. This protocol employed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P). The review will apply the PRISMA extension for scoping reviews to present the results. The scoping review will adapt the five principles set forth in the Ottawa Charter to categorise the outcomes and uses its strategies to define the interventions. Data bases searched are Ovid Medline, Embase, Cochrane Library, CINAHL, SCOPUS, CABI, JBI Evidence Synthesis and grey literature. The database last searched was January 2021. ETHICS AND DISSEMINATION: This review does not require ethics approval. Our dissemination strategy includes peer review publication, policy brief, presentation at conferences and relevant stakeholders.

Improving Social Justice in COVID-19 Health Research: Interim Guidelines for Reporting Health Equity in Observational Studies.

The COVID-19 pandemic has highlighted the global imperative to address health inequities. Observational studies are a valuable source of evidence for real-world effects and impacts of implementing COVID-19 policies on the redistribution of inequities. We assembled a diverse global multi-disciplinary team to develop interim guidance for improving transparency in reporting health equity in COVID-19 observational studies. We identified 14 areas in the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) checklist that need additional detail to encourage transparent reporting of health equity. We searched for examples of COVID-19 observational studies that analysed and reported health equity analysis across one or more social determinants of health. We engaged with Indigenous stakeholders and others groups experiencing health inequities to co-produce this guidance and to bring an intersectional lens. Taking health equity and social determinants of health into account contributes to the clinical and epidemiological understanding of the disease, identifying specific needs and supporting decision-making processes. Stakeholders are encouraged to consider using this guidance on observational research to help provide evidence to close the inequitable gaps in health outcomes.

A protocol for a pilot cluster randomized control trial of e-vouchers and mobile phone application to enhance access to maternal health services in Cameroon.

BACKGROUND: Cameroon still has relatively high maternal mortality rate (MMR) of 596/100,000 live births. Approximately 40% of births are unattended by skilled healthcare personnel with high out-of-pocket expenditures. Poor resource allocation, poorly functioning referral systems, long trekking distances to health facilities, all of which lead to low rates of use of maternal health services. OBJECTIVES: The aim of this pilot study is to explore perception and acceptability of mobile health (mhealth) and e-voucher and to determine the feasibility of conducting a large cluster randomized trial to determine the effects of combining e-vouchers and a mobile application compared with usual care in improving access to and use of maternal health services. METHODS: This is a multimethod study that comprises two phases. The first phase is the development of the mobile phone app, which includes a qualitative formative study through in-depth key informant interviews and focus group discussions. The second phase is a cluster randomized control trial assessing the combination of e-vouchers and a mobile application compared with usual care in improving access to and use of maternal health services. Feasibility will be determined based on evaluating randomization, contamination, enrollment rate, complete follow up, compliance rate, success in matching data from different sources, and data completeness. ETHICS AND DISCUSSION: Ethics approval has been granted, and the trial has been registered in the Pan-African Clinical Trials Registry. We will disseminate our findings through peer-reviewed manuscripts and conference presentations. Findings from this study will inform the design and conduct of a larger randomized trial. TRIAL REGISTRATION: PACTR201808703097367. The trial on the Pan African Clinical Trials Registry.

Government policy interventions to reduce human antimicrobial use: A systematic review and evidence map.

BACKGROUND: Growing political attention to antimicrobial resistance (AMR) offers a rare opportunity for achieving meaningful action. Many governments have developed national AMR action plans, but most have not yet implemented policy interventions to reduce antimicrobial overuse. A systematic evidence map can support governments in making evidence-informed decisions about implementing programs to reduce AMR, by identifying, describing, and assessing the full range of evaluated government policy options to reduce antimicrobial use in humans. METHODS AND FINDINGS: Seven databases were searched from inception to January 28, 2019, (MEDLINE, CINAHL, EMBASE, PAIS Index, Cochrane Central Register of Controlled Trials, Web of Science, and PubMed). We identified studies that (1) clearly described a government policy intervention aimed at reducing human antimicrobial use, and (2) applied a quantitative design to measure the impact. We found 69 unique evaluations of government policy interventions carried out across 4 of the 6 WHO regions. These evaluations included randomized controlled trials (n = 4), non-randomized controlled trials (n = 3), controlled before-and-after designs (n = 7), interrupted time series designs (n = 25), uncontrolled before-and-after designs (n = 18), descriptive designs (n = 10), and cohort designs (n = 2). From these we identified 17 unique policy options for governments to reduce the human use of antimicrobials. Many studies evaluated public awareness campaigns (n = 17) and antimicrobial guidelines (n = 13); however, others offered different policy options such as professional regulation, restricted reimbursement, pay for performance, and prescription requirements. Identifying these policies can inform the development of future policies and evaluations in different contexts and health systems. Limitations of our study include the possible omission of unpublished initiatives, and that policies not evaluated with respect to antimicrobial use have not been captured in this review. CONCLUSIONS: To our knowledge this is the first study to provide policy makers with synthesized evidence on specific government policy interventions addressing AMR. In the future, governments should ensure that AMR policy interventions are evaluated using rigorous study designs and that study results are published. PROTOCOL REGISTRATION: PROSPERO CRD42017067514.

Correction: Interventions to improve resilience in physicians who have completed training: A systematic review.

[This corrects the article DOI: 10.1371/journal.pone.0210512.].

Interventions to improve resilience in physicians who have completed training: A systematic review.

BACKGROUND: Resilience is a contextual phenomenon where a complex and dynamic interplay exists between individual, environmental, and socio-cultural factors. With growing interest in enhancing resilience in physicians, given their high risk for experiencing prolonged or intense stress, effective strategies are necessary to improve resilience and reduce negative outcomes including burnout. The objective of this review was to identify effective interventions to improve resilience in physicians who have completed training, working in any setting. METHODS AND FINDINGS: We included randomized controlled trials (RCT), and observational studies (including pilot studies) published in English, French, and Spanish that included an intervention to improve resilience in physicians who have completed training. We included studies that implemented interventions to reduce burnout, anxiety, and depression or to improve empathy to ultimately enhance resilience, rather than studies designed solely to reduce stress or trauma-induced stress. We performed a systematic search of Medline, EMBASE, PsychInfo, CINAHL and Cochrane Library with no publication year limit. The last search was conducted on March 29, 2017. We used random effect models to calculate pooled standardized mean differences. Resilience was the primary outcome measure using validated resilience scores. Secondary outcome measures included proxy measures of resilience such as burnout, empathy, anxiety and depression. Our search strategy identified 7,579 records;74 met the criteria for full-text review. Seventeen studies were included in the final review published between 1998 and 2016 of which 9 (4 RCT, 5 observational) had physician data extractable. Interventions varied greatly regarding their approach, duration, and follow-up. Two RCTs measured resilience using validated scales; both found a significant improvement. No meta-analysis for resilience was conducted due to the presence of high clinical and methodological heterogeneity. CONCLUSIONS: Our systematic review demonstrates that there is weak evidence to support one intervention over another to improve resilience in physicians who have completed training. The quality of evidence for the outcomes ranged from very low to low. There is a need for a consensus on the definition of resilience and how it is measured. Longer follow-up is required to ensure any intervention effects are sustained over time.