U.S. trainees' experiences of ethical challenges during research in low- and middle-income countries: A mixed methods study.

High-income country (HIC) trainees are participating in research in low- and middle-income countries (LMIC) in increasing numbers, yet the ethical challenges they face have not been well described. We conducted a mixed methods study of U.S. graduate and undergraduate students who conducted research in LMIC, including an online survey and semi-structured interviews. Among 123 online survey respondents, 31% reported ethical challenges and nearly two-thirds of respondents did not feel well prepared to deal with ethical challenges. Qualitative analysis of the 17 semi-structure interviews and narrative survey responses revealed many themes of 'ethics in practice': challenges in setting research priorities, navigating relationships with host country partners, scope of research practice, and human subject protections. Respondents reported that pre-departure trainings were not reflective of ethical frameworks or research contexts in LMIC, and few described seeking host mentor help in addressing ethical challenges. These results suggest a need for improvements in training, oversight and mentorship of trainee researchers, and to further engage both HIC and LMIC institutions, educators and researchers in addressing ethical issues.

Unit Costing of Health Extension Worker Activities in Ethiopia: A Model for Managers at the District and Health Facility Level.

BACKGROUND: Over the last decade, Ethiopia has made impressive national improvements in health outcomes, including reductions in maternal, neonatal, infant, and child mortality attributed in large part to their Health Extension Program (HEP). As this program continues to evolve and improve, understanding the unit cost of health extension worker (HEW) services is fundamental to planning for future growth and ensuring adequate financial support to deliver effective primary care throughout the country. METHODS: We sought to examine and report the data needed to generate a HEW fee schedule that would allow for full cost recovery for HEW services. Using HEW activity data and estimates from national studies and local systems we were able to estimate salary costs and the average time spent by an HEW per patient/community encounter for each type of services associated with specific users. Using this information, we created separate fee schedules for activities in urban and rural settings with two estimates of non-salary multipliers to calculate the total cost for HEW services. RESULTS: In the urban areas, the HEW fees for full cost recovery of the provision of services (including salary, supplies, and overhead costs) ranged from 55.1 birr to 209.1 birr per encounter. The rural HEW fees ranged from 19.6 birr to 219.4 birr. CONCLUSION: Efforts to support health system strengthening in low-income settings have often neglected to generate adequate, actionable data on the costs of primary care services. In this study, we have combined time-motion and available financial data to generate a fee schedule that allows for full cost recovery of the provision of services through billable health education and service encounters provided by Ethiopian HEWs. This may be useful in other country settings where managers seek to make evidence-informed planning and resource allocation decisions to address high burden of disease within the context of weak administrative data systems and severe financial constraints.

Outputs and Growth of Primary Care Databases in the United Kingdom: Bibliometric Analysis.

BACKGROUND: Electronic health database (EHD) data is increasingly used by researchers. The major United Kingdom EHDs are the 'Clinical Practice Research Datalink' (CPRD), 'The Health Improvement Network' (THIN) and 'QResearch'. Over time, outputs from these databases have increased, but have not been evaluated. OBJECTIVE: This study compares research outputs from CPRD, THIN and QResearch assessing growth and publication outputs over a 10-year period (2004-2013). CPRD was also reviewed separately over 20 years as a case study. METHODS:  Publications from CPRD and QResearch were extracted using the Science Citation Index (SCI) of the Thomson Scientific Institute for Scientific Information (Web of Science). THIN data was obtained from University College London and validated in Web of Science. All databases were analysed for growth in publications, the speciality areas and the journals in which their data have been published. RESULTS: These databases collectively produced 1,296 publications over a ten-year period, with CPRD representing 63.6% (n=825 papers), THIN 30.4% (n=394) and QResearch 5.9% (n=77). Pharmacoepidemiology and General Medicine were the most common specialities featured. Over the 9-year period (2004-2013), publications for THIN and QResearch have slowly increased over time, whereas CPRD publications have increased substantially in last 4 years with almost 75% of CPRD publications published in the past 9 years. CONCLUSION: These databases are enhancing scientific research and are growing yearly, however display variability in their growth. They could become more powerful research tools if the National Health Service and general practitioners can provide accurate and comprehensive data for inclusion in these databases.

Process evaluation of knowledge transfer across industries: Leveraging Coca-Cola's supply chain expertise for medicine availability in Tanzania.

Persistent gaps in the availability of essential medicines have slowed the achievement of global health targets. Despite the supply chain knowledge and expertise that ministries of health might glean from other industries, limited empirical research has examined the process of knowledge transfer from other industries into global public health. We examined a partnership designed to improve the availability of medical supplies in Tanzania by transferring knowledge from The Coca-Cola system to Tanzania's Medical Stores Department (MSD). We conducted a process evaluation including in-depth interviews with 70 participants between July 2011 and May 2014, corresponding to each phase of the partnership, with focus on challenges and strategies to address them, as well as benefits perceived by partners. Partners faced challenges in (1) identifying relevant knowledge to transfer, (2) translating operational solutions from Coca-Cola to MSD, and (3) maintaining momentum between project phases. Strategies to respond to these challenges emerged through real-time problem solving and included (1) leveraging the receptivity of MSD leadership, (2) engaging a boundary spanner to identify knowledge to transfer, (3) promoting local recognition of commonalities across industries, (4) engaging external technical experts to manage translation activities, (5) developing tools with visible benefits for MSD, (6) investing in local relationships, and (7) providing time and space for the partnership model to evolve. Benefits of the partnership perceived by MSD staff included enhanced collaboration and communication, more proactive orientations in managing operations, and greater attention to performance management. Benefits perceived by Coca-Cola staff included strengthened knowledge transfer capability and enhanced job satisfaction. Linking theoretical constructs with practical experiences from the field, we highlight the challenges, emergent strategies, and perceived benefits of a partnership across industry boundaries that may be useful to others seeking to promote the transfer of knowledge to improve global health.

Research Outputs of England's Hospital Episode Statistics (HES) Database: Bibliometric Analysis.

BACKGROUND: Hospital administrative data, such as those provided by the Hospital Episode Statistics (HES) database in England, are increasingly being used for research and quality improvement. To date, no study has tried to quantify and examine trends in the use of HES for research purposes. OBJECTIVE: To examine trends in the use of HES data for research. METHODS: Publications generated from the use of HES data were extracted from PubMed and analysed. Publications from 1996 to 2014 were then examined further in the Science Citation Index (SCI) of the Thompson Scientific Institute for Science Information (Web of Science) for details of research specialty area. RESULTS: 520 studies, categorised into 44 specialty areas, were extracted from PubMed. The review showed an increase in publications over the 18-year period with an average of 27 publications per year, however with the majority of output observed in the latter part of the study period. The highest number of publications was in the Health Statistics specialty area. CONCLUSION: The use of HES data for research is becoming more common. Increase in publications over time shows that researchers are beginning to take advantage of the potential of HES data. Although HES is a valuable database, concerns exist over the accuracy and completeness of the data entered. Clinicians need to be more engaged with HES for the full potential of this database to be harnessed.

State-level spending on health care and social services for people living with HIV/AIDS in the USA: a systematic review.

Every year for the past decade, approximately 50,000 people have been diagnosed with HIV or AIDS in the USA, and the incidence of HIV/AIDS varies considerably from state to state. Studies have shown that health care services, most notably treatment with combination antiretroviral therapy, can help people living with HIV/AIDS (PLWHA) live healthier, longer lives, and prevent the spread of HIV from person to person. In addition, social services, such as housing support and provision of meals, have also shown to be important for helping PLWHA adhere to antiretroviral treatment and maintain contact with health care providers for improved health outcomes. Although spending on health care and social services for PLWHA varies across the USA, the relationship between state-level spending on these services and HIV/AIDS-related outcomes is not clear. We therefore conducted a systematic review of peer-reviewed literature to identify studies that explore state-level spending on health care services and/or social services for PLWHA and HIV/AIDS-related health outcomes in the USA.

Policy and programme implications of unmet need for family planning in Pakistan.

INTRODUCTION: With the contraceptive prevalence rate (CPR) at 30% in 2006-7, the rates of contraception use among married women of reproductive age (MWRA) in Pakistan are among the lowest in the region. This paper explores some options of unmet need as a means of addressing the low CPR. METHODS: We conducted secondary data analysis of the Pakistan Demographic Health Survey (PDHS) 2006-7 to understand the context of unmet need in Pakistan. Univariate and multiple regression techniques were used to understand associations. The numbers of women with unmet need were calculated by multiplying PDHS proportions with actual population figures. RESULTS: There are 5.7 million women with an unmet need; 2.4 million with a need to space and 3.3 million with a need to limit. Unmet need decreases with age, increases with the number of children and increasing education, and is higher among poor women. Structural factors such as rural residence and exposure to family planning (FP) programmes and messages are relevant for unmet need for spacing, but not for unmet need for limiting. There are twice as many women in Pakistan with an unmet need for FP than those who avail FP services. Additionally there is much more need to limit than the need to space. In fact the need to limit is nearly 10 fold higher than the services for long-term methods. Structural interventions, that increase service delivery, quality, and uptake may address unmet need in the short-term, must be complemented with demand creation and behaviour-change interventions. All of these issues must be addressed concomitantly with research to understand how best to harness the "market forces" that are responsible for over half of all FP services.

Performance and measurement of a community-based distribution model of family planning services in Pakistan.

INTRODUCTION: Community-based distribution (CBD) has been successfully applied to family planning (FP) services worldwide. It forms the basis for the large lady health worker (LHW) programme in Pakistan which serves a limited number of women with contraception services. Thus, the concept has seen limited application in Pakistan. We present the outcomes of a CBD model that was implemented in 49 districts across Pakistan by a non-government organization (NGO). METHODS: The Marie Stopes Society (MSS) developed a CBD model around its fixed centres and reached around half a million married women of reproductive age (MWRA) with services. The services provided included outreach, counselling, condoms, pills, injections, and referrals for intrauterine contraceptive devices (IUCDs) and other reproductive health services. Services were provided in peri-urban locations for a subsidized fee using a businesslike target setting approach. The results of the programme were assessed by triangulating inception records against a cross-sectional end-of-project survey and service delivery records. RESULTS: The contraceptive prevalence rate (CPR) had increased from 38% to 51% by project-end with modern method use increasing by 50-200% and traditional method use remaining unchanged. Unmet need and self-reported pregnancy rates fell correspondingly. Approximately 73,500 new users were added to the initial user registered numbers to a total of 132,300; MSS accounted for 53,000 per year at the end of the project, which matched the commodities supplied by the NGO. CONCLUSIONS: The MSS CBD model presents a viable option for scaling effective FP services that may be replicated and scaled up with either donor support or by contracting out by the government. Triangulation of multiple data sources can provide more in-depth assessment of service delivery programmes and provide inferences that can inform service delivery.

International Classification of Diseases-9th revision coding for preeclampsia: how accurate is it?

OBJECTIVE: The purpose of this study was to evaluate the accuracy of the International Classification of Diseases-9th revision codes for preeclampsia and eclampsia. STUDY DESIGN: The University of Illinois Medical Center at Chicago discharge database was used to identify 135 women from 1999 through 2001 whose disease was coded as having preeclampsia or eclampsia. With American College of Obstetrics and Gynecology criteria as the gold standard, the diagnosis that was determined through chart review was compared with the International Classification of Diseases-9th revision code that was present in the discharge database. Patients were classified as true cases if the International Classification of Diseases-9th revision code matched the American College of Obstetricians and Gynecologists diagnosis; the positive predictive value of the code was then calculated. RESULTS: The overall positive predictive value for the complete sample was only 54%, but the positive predictive value for severe preeclampsia was 84.8%, which was high compared with mild preeclampsia (45.3%) and eclampsia (41.7%). Diagnostic (clinician) error was the most common reason for miscoding error. CONCLUSION: The findings suggest that International Classification of Diseases-9th revision codes for preeclampsia/eclampsia vary greatly in their accuracy of diagnosis. Therefore, a review of medical records is required when data are being gathered on the incidence of preeclampsia and eclampsia.