Crise global da atenção primária à saúde / Global crisis in primary health care / Crisis global de la atención primaria

Enquanto no Norte Global se discute uma crise na Atenção Primária à Saúde, a maioria dos países nunca chegou a constituir sistemas de saúde baseados propriamente numa atenção primária robusta. Nesse cenário, o Brasil apresenta uma tendência mais favorável, com conquistas importantes para a atenção primária e a medicina de família e comunidade nos últimos dez anos. Restam desafios a serem superados para que o Sistema Único de Saúde alcance níveis satisfatórios de acesso a seus serviços, com profissionais adequadamente formados e valorizados pela população.

While the Global North is discussing a crisis in primary health care, the majority of countries have never managed to establish health systems based on robust primary care. Brazil presents a more favorable trend, with important achievements for primary care and family practice over the last ten years. There are still challenges to be overcome so that the Unified Health System achieves satisfactory levels of access to its services, with professionals who are properly trained and valued by the public.

Mientras que en el Norte Global se habla de una crisis de la atención primaria, la mayoría de los países nunca han creado realmente sistemas sanitarios basados en una atención primaria robusta. Brasil, muestra una tendencia más favorable, con importantes logros para la atención primaria y la medicina familiar y comunitaria en los últimos diez años. Aún quedan retos por superar para que el Sistema Único de Salud alcance niveles satisfactorios de acceso a sus servicios, con profesionales debidamente formados y valorados por la población.

Continuity of care during severe civil unrest with a model of community-based HIV care: a retrospective cohort study from Haiti.

Background: There are limited data on the effectiveness of differentiated service delivery (DSD) for HIV care during sociopolitical turmoil. We assessed outcomes with a DSD model of care that includes patient choice between community-based antiretroviral therapy (ART) centres, home-based ART dispensing, or facility-based care at GHESKIO clinic during a period of severe civil unrest in Port-au-Prince, Haiti. Methods: This retrospective analysis included data on patients with at least one HIV visit at GHESKIO between May 1, 2019, and December 31, 2021. Multivariable logistic regression models were used to assess predictors of attending ≥1 community visit during the study period, and failure to attend timely visits. HIV-1 RNA test results were reported among patients who had been ART for ≥3 months at last visit. Findings: Of the 18,625 patients included in the analysis, 9659 (51.9%) attended at least one community visit. The proportion of community visits ranged from 0.3% (2019) to 44.1% (2021). Predictors of ≥1 community visit included male sex (aOR: 1.13; 95% CI: 1.06, 1.20), secondary education (aOR: 1.07; 95% CI: 1.01, 1.14), income > $USD 1.00/day (aOR: 1.24; 95% CI: 1.14, 1.35), longer duration on ART (aOR: 1.08 per additional year; 95% CI: 1.07, 1.09), and residence in Carrefour/Gressier (p < 0.0001 in comparisons with all other zones). Younger age and shorter time on ART were associated with late visits and loss to follow-up. Among 12,586 patients with an on-time final visit who had been on ART for ≥3 months, 11,131 (88.4%) received a viral load test and 9639 (86.6%) had HIV-1 RNA < 1000 copies/mL. Interpretation: The socio-political situation in Haiti has presented extraordinary challenges to the health care system, but retention and viral suppression rates remain high with a model of community-based HIV care. Additional interventions are needed to improve outcomes for younger patients, and those with shorter time on ART. Funding: No funding.

Creation of an Emergency Care Capacity Assessment Tool for Facilities in Austere Environments.

INTRODUCTION: Facilities in austere environments may consider emergency care beyond their scope. Often patients with high-acuity conditions have no other choice than to present to these facilities. The disconnect between the intent of health systems planners and the reality faced by providers manifests as facilities unable to manage such cases.The Indian Health Service, with a range of stakeholders, developed an emergency care delivery assessment tool for facilities in austere environments, designed to identify deficiencies in facility readiness for emergency care delivery across four areas: 1. Procedural2. Human resources3. Non-pharmacologic material resources4. Pharmacologic material resources. METHODS: The tool's underlying architecture is a resource matrix similar to hospital-based tools, using the "Facility" component of the WHO Emergency Care Systems Framework as the Y-axis and undifferentiated presentations taught by the WHO basic emergency care course, advanced trauma life support, and advanced life support in obstetrics as the X-axis. The tool was piloted at a remote frontier clinic. RESULTS: We found 48 deficiencies: 7 procedural, 1 human resources, 31 non-pharmacologic materials, and 9 pharmacologic materials. We aggregated deficiencies by facility function to assess the capacity to perform each. We also aggregated deficiencies by clinical presentation to identify targets for educational interventions. CONCLUSION: We successfully created a novel emergency care capacity assessment tool for use in austere environments using materials with broad international consensus. The successful pilot found deficiencies across all 4 areas. This tool may be useful in many other remote domestic facilities and rural health posts in low- and middle-income countries.

Addressing Delayed Hospital Discharges for Patients With Intellectual and Developmental Disabilities and a Mental Illness.

Adults with intellectual and developmental disabilities (IDD) who also have a co-occurring mental illness are almost five times as likely to experience a delayed hospital discharge as adults with mental illness only. Such delays occur when a patient no longer requires hospital-level care but cannot be discharged, often because of a lack of appropriate postdischarge settings. Delayed discharges contribute to poor patient outcomes, increased system costs, and delayed access to care. Recently, practice guidance was developed in Canada, identifying 10 components of successful transitions for this population. Core to this guidance is a patient-centered, cross-sectoral approach, including the patient, family, hospital team, community health care providers, and IDD providers.

Beliefs of Pentecostal pastors concerning the use of antiretroviral treatment among Pentecostal Christians living with HIV in a suburb of Cape Town-South Africa: a community health systems lens.

The global public health community accepts antiretroviral therapy (ART) for controlling and managing HIV. However, within some communities, claims of faith or miraculous healing of HIV and AIDS by Pentecostal pastors continue to spark controversies. This paper reports on an exploratory qualitative study to explore the beliefs held by Pentecostal pastors regarding the use of ART among Pentecostal Christians who are living with HIV (PCLH). Twenty Pentecostal pastors from two informal settlements in Cape Town, South Africa, were purposefully selected. Open-ended, semi-structured, in-depth individual interviews were conducted on their religious beliefs concerning ART adherence. Interviews were conducted in English, audiotaped, and transcribed verbatim before being imported to the Atlas-ti 2023 software program for thematic data analysis. Since our study was guided by the relational community health system (CHS) model a hybrid deductive-inductive thematic analysis was used. Two contrasting themes about the influence of the religious beliefs of Pentecostal pastors were identified: The first theme and its associated subthemes highlight the lack of basic HIV and ART knowledge among pastors. Consequently, these pastors tend to nudge their Christians to rely more on faith and spiritual healing at the expense of adherence to ART. The second theme and the associated sub-themes suggest that some pastors possess some basic HIV knowledge and understand the role of ART and how it works. This group of pastors advise their congregants to use ART and other healthcare services in tandem with spiritual rituals, faith, and prayers. Our findings highlight the need for functional community-based structures, such as community health committees (CHCs) and health facility management committees (HFMCs), in settings where complex interaction within the belief systems, practices, and norms of some stakeholders can influence people's health-seeking behaviours such as adhering to chronic medications like ART.

Weight management medications for chronic use in 37 veterans affairs medical centers-A medication use evaluation.

Rationale: Controlled trials have demonstrated successful weight loss associated with certain weight management medications (WMMs). However, there are limited real-world data on prescribing patterns and efficacy and safety profiles of WMMs in Veterans Affairs (VA) patients. Objective: To evaluate: utilization patterns of WMMs liraglutide, naltrexone/bupropion, orlistat, phentermine, phentermine/topiramate, and semaglutide; weight loss at three, six, twelve, and more than 12 months; safety; and treatment barriers. Methods: A retrospective, cross-sectional medication use evaluation (MUE) was conducted using electronic health records of outpatient Veterans newly initiated on WMMs at 37 VA Medical Centers between 1 March 2020 and 31 March 2022. Chart review was used to identify WMM utilization and capture rates of clinical response, defined as 5% and 10% or greater weight loss at the final weight, adverse drug events (ADEs), non-adherence, and discontinuations. Site-specific surveys evaluated local practices and barriers. Results: Among 1959 eligible Veterans, semaglutide, phentermine/topiramate, and orlistat were most frequently prescribed. The clinical response was highest among phentermine/topiramate, liraglutide, and semaglutide. Naltrexone/bupropion and phentermine demonstrated the highest and lowest ADE rates, respectively. Potential barriers to WMM utilization and successful treatment by site reports were drug shortages, patient perceptions of therapeutic course, personal preferences, and VA WMM use criteria. Conclusions: Smaller weight loss and higher discontinuation rates were observed relative to clinical trials. The MUE data allow for better assessment of benefits and risks for Veterans prescribed WMMs.

Reorienting health systems towards Primary Health Care in South Asia.

This series, "Primary health care in South Asia", is an effort to provide region-specific, evidence-based insights for reorienting health systems towards PHC. Led by regional thinkers, this series draws lessons from five countries in South Asia: Bangladesh, India, Nepal, Pakistan, and Sri Lanka. This is the last paper in the series that outlines points for future action. We call for action in three areas. First, the changing context in the region, with respect to epidemiological shifts, urbanisation, and privatisation, presents an important opportunity to appraise existing policies on PHC and reformulate them to meet the evolving needs of communities. Second, reorienting health systems towards PHC requires concrete efforts on three pillars-integrated services, multi-sectoral collaboration, and community empowerment. This paper collates nine action points that cut across these three pillars. These action points encompass contextualising policies on PHC, scaling up innovations, allocating adequate financial resources, strengthening the governance function of health ministries, establishing meaningful public-private engagements, using digital health tools, reorganising service delivery, enabling effective change-management processes, and encouraging practice-oriented research. Finally, we call for more research-policy-practice networks on PHC in South Asia that can generate evidence, bolster advocacy, and provide spaces for cross-learning. Funding: WHO SEARO funded this paper. This source did not play any role in the design, analysis or preparation of the manuscript.

Strengthening primary health care through community health workers in South Asia.

The growing health challenges in South Asia require further adaptations of community health worker (CHW) programs as a key element of primary health care (PHC). This paper provides a comparative analysis of CHW programs in five countries (Bangladesh, India, Nepal, Pakistan, and Sri Lanka), examines successes and challenges, and suggests reforms to better ensure highly performing CHW programs. To examine CHW programs in the region, we conducted a narrative review of the peer-reviewed and grey literatures, as well as eliciting opinions from experts. Common roles of CHWs include health education, community mobilization, and community-based services, particularly related to reproductive, maternal, neonatal, and child health. Some countries utilize CHWs for non-communicable diseases and other emerging health issues. To maximize the potential contribution of CHWs to achieving Universal Health Coverage, we recommend future research and policy focus on strengthening existing health systems to support the expansion of CHWs roles and better integrating of CHWs into national PHC systems. This is Paper 4 in the Series on Primary Health Care in South Asia, addressing areas that have the potential to revitalize health systems in South Asian countries. Funding: The authors received financial support from the Department of Health Systems Development, WHO South-East Asia Regional Office (WHO SEAR).

Examining the development and utilisation of Community-Based Health Information Systems (CBHIS) in Africa: A Scoping Review.

Introduction: The community-based health information system (CBHIS) is a vital component of the community health system, as it assesses community-level healthcare service delivery and generates data for community health programme planning, monitoring, and evaluation. CBHIS promotes data-driven decision-making, by identifying priority interventions and programs, guiding resource allocation, and contributing to evidence-based policy development. Objective: This scoping review aims to comprehensively examine the use of CBHIS in African countries, focusing on data generation, pathways, utilization of CBHIS data, community accessibility to the data and use of the data to empower communities. Methods: We utilised Arksey and O'Malley's scoping review methodology. We searched eight databases: PubMed, EMBASE, HINARI, Cochrane Library, Web of Science, Scopus, Google Scholar, and grey literature databases (Open Grey and OAIster). We synthesized findings using a thematic approach. Results: Our review included 55 articles from 27 African countries, primarily in Eastern and Southern Africa, followed by West Africa. Most of the studies were either quantitative (42%) or qualitative (33%). Paper-based systems are primarily used for data collection in most countries, but some have adopted electronic/mobile-based systems or both. The data flow for CBHIS varies by country and the tools used for data collection. CBHIS data informs policies, resource allocation, staffing, community health dialogues, and commodity supplies for community health programmes. Community dialogue is the most common approach for community engagement, empowerment, and sharing of CBHIS data with communities. Community empowerment tends towards health promotion activities and health provider-led approaches. Conclusion: CBHIS utilizes both paper-based and electronic-based systems to collect and process data. Nevertheless, most countries rely on paper-based systems. Most of the CBHIS investments have focused on its digitization and enhancing data collection, process, and quality. However, there is a need to shift the emphasis towards enabling data utilisation at the community level and community empowerment.

For community health services and systems to work well, health managers and other data users, including policy and decision-makers, need a community-based health information system (CBHIS) that produces reliable and timely information on how well these services are working and that supports the use of CBHIS data to improve community health service delivery. This scoping review aimed to explore the use of CBHIS in African countries. It focused on data generation, pathways, use of CBHIS data, community data access, and use of CBHIS data to empower communities. The review authors collected and analysed all relevant studies to answer this question and found 55 articles from 27 African countries. The review found that most countries use paper-based information systems for data collection, while some have adopted electronic and digital systems. CBHIS also collects information on human resources, medicines, and supply systems. CBHIS data are used to guide policy development, allocate resources, track commodities supplies, staff for community health programmes and organise community health dialogues. Community dialogue is the most common approach for engaging, empowering, and sharing CBHIS data with communities. Community empowerment involves activities that promote health and health provider-led approaches. There is a need to focus on enabling the use of data at the community level and empowerment.

Rural-urban differences in health service utilization in upper-middle and high-income countries: a scoping review.

PURPOSE: This scoping review aims to understand the extent and attributes of literature evaluating differences between rural and urban populations' utilization of health services in upper-middle and high-income countries. METHOD: The review was conducted in line with established scoping review methodology guidelines. We used the "Participants, Concept and Context" framework to guide the inclusion criteria and determination of the review's scope. Studies published over a 15-year period (2008-2022) were identified using Embase, Medine, PubMed, and Scopus databases. Study attributes, areas of focus and findings were reviewed and extracted. RESULTS: The search identified 179 studies. The number of studies published looking at rural-urban differences in health service utilization has increased over time. The focus of these studies is relatively evenly split between primary and secondary sectors. The majority of studies observed less service utilization by rural populations than urban-especially so in primary-sector services. When higher rural utilization of secondary services was observed this was frequently attributed to poor access to other services that would have had the potential to mitigate the secondary demand. Studies were not commonly grounded in principles of equity or fairness and rarely offered value judgements on observed differences in utilization. There were limited system-level studies - the vast majority being disease- or service-specific analyses. We consider this a notable gap in the literature. CONCLUSION: This scoping review identifies key parameters of studies on rural-urban variation in health service utilization. The finding that most studies observed rural populations utilized comparatively less services is concerning, in the context of general evidence about high levels of health need in rural communities. Future system-level research considering the combined variations in need and utilization appears a priority.

Pathways to strengthen the climate resilience of health systems in the Peruvian Amazon by working with Indigenous leaders, communities and health officers.

BACKGROUND: Indigenous knowledge and responses were implemented during the COVID-19 pandemic to protect health, showcasing how Indigenous communities participation in health systems could be a pathway to increase resilience to emergent hazards like climate change. This study aimed to inform efforts to enhance climate change resilience in a health context by: (1) examining if and how adaptation to climate change is taking place within health systems in the Peruvian Amazon, (2) understanding how Indigenous communities and leaders' responses to climatic hazards are being articulated within the official health system and (3) to provide recommendations to increase the climate change resilience of Amazon health systems. METHODS: This study was conducted among two Peruvian Amazon healthcare networks in Junin and Loreto regions. A mixed methodology design was performed using a cross-sectional survey (13 healthcare facilities), semistructured interviews (27 official health system participants and 17 Indigenous participants) and two in-person workshops to validate and select key priorities (32 participants). We used a climate-resilient health system framework linked to the WHO health systems building blocks. RESULTS: Indigenous and official health systems in the Peruvian Amazon are adapting to climate change. Indigenous responses included the use of Indigenous knowledge on weather variability, vegetal medicine to manage health risks and networks to share food and resources. Official health responses included strategies for climate change and response platforms that acted mainly after the occurrence of climate hazards. Key pathways to articulate Indigenous and official health systems encompass incorporating Indigenous representations in climate and health governance, training the health work force, improving service delivery and access, strengthening the evidence to support Indigenous responses and increasing the budget for climate emergency responses. CONCLUSIONS: Key resilience pathways call for a broader paradigm shift in health systems that recognises Indigenous resilience as valuable for health adaptation, moves towards a more participatory health system and broadens the vision of health as a dimension inherently tied to the environment.

[Evidence for Health Promotion in Brazil: report on a rapid response serviceEvidencia para la promoción de la salud en Brasil: informe sobre un servicio de respuesta rápida]. / Evidências para a Promoção da Saúde no Brasil: relato de um serviço de resposta rápida.

Objective: Present the experience of a rapid response service to support decision-making in health systems. Methodology: Description of the processes and results of a service that produces rapid reviews and evidence maps to support decision-making under the National Health Promotion Policy, as well as the authors' perception of the work process. Results: The rapid response service started in 2020. By December 2023, 54 rapid reviews and five evidence maps had been produced, covering nine health promotion topics. These products were developed in 14 stages by a team made up of a coordinator, supervisors, proofreaders, and a librarian. The development of rapid responses involved a knowledge translation process, with continuous interactions between the requesting teams and production teams. Establishing effective communication was a critical factor in delivering products on time and in line with the needs of decision-makers and their supporters. Conclusion: Rapid response services can help improve the use of evidence for decision-making in health policies and health systems.

Objetivo: Presentación de la experiencia de un servicio de respuesta rápida para brindar apoyo a la toma de decisiones en materia de salud. Método: Se describen los procesos y resultados de un servicio de elaboración de revisiones rápidas y mapas de evidencia para brindar apoyo a la toma de decisiones en el marco de la Política Nacional de Promoción de la Salud, así como la percepción de los autores sobre el proceso de trabajo. Resultados: El servicio de respuesta rápida se inició en el 2020. Hasta diciembre del 2023, se habían elaborado 54 revisiones rápidas y cinco mapas de evidencia, que abarcaban nueve temas de promoción de la salud. Estos productos fueron elaborados en 14 etapas por un equipo formado por un coordinador, varios supervisores y revisores y un bibliotecario. La elaboración de respuestas rápidas fue un proceso de traducción del conocimiento e implicó una interacción continua entre los equipos solicitantes y el equipo de elaboración. El establecimiento de una comunicación eficaz fue un factor decisivo para entregar los productos a tiempo y en consonancia con las necesidades de los responsables de la toma de decisiones y su personal de apoyo. Conclusión: Los servicios de respuesta rápida pueden ayudar a mejorar el uso de evidencia en la toma de decisiones relacionadas con las políticas y los sistemas de salud.

The critical elements of the health system that could make for resilience in the World Health Organization African Region: a scoping review.

Background: Unpredictable events, such as the outbreak of infectious diseases and humanitarian crises, are putting a strain on health care systems. As a result, African countries will need to prepare themselves with appropriate strategies to withstand such occurrences. Therefore, the purpose of this scoping review was to map available evidence about what type and what components of health systems are needed to help countries cope with health emergencies and to foster health system resilience in the WHO African Region. Methods: A systematic search was performed independently in Scopus and PubMed electronic databases as well as grey literature. Studies were selected based on set eligibility criteria based on the Joanna Brigg's Institute (JBI) methodology for scoping reviews. The key findings were focused on health system resilience and were mapped based on the WHO's core health system components. Our data were tabulated, and a narrative synthesis was conducted. Results: A total of 28 studies were included in this scoping review, mostly conducted in the WHO African Region and region of the Americas. Studies focused on a variety of strategies, such as the continuous delivery of essential services, the strengthening of the health workforce, including community health care workers, community engagement, the provision of protective mechanisms for the health workforce, and flexible leadership and governance measures. Conclusion: Our findings suggest that strategies to improve health system resilience must include all areas of the healthcare delivery process, including primary care. A resilient health system should be ready for a crisis and have adaptable policies in place to offer adequate response at all levels, as well as post-recovery planning. Such health systems should also seek for continuous improvement. More research is needed to assess the efficacy of initiatives for improving health system resilience, particularly in vulnerable African health systems.

Strengthening the effectiveness of community health system: Assessing the factors that enhance or constrain the delivery of health services within communities in Nigeria.

INTRODUCTION: Sub-optimal community health service delivery (CHSD) has been a challenge constraining community health systems (CHS) globally, especially in developing countries such as Nigeria. This paper examined the key factors that either enhance or constrain CHSD in Nigeria at the individual, community/facility and governmental levels while recommending evidence-based solutions for sustaining and improving CHSD within the framework of CHS. METHODS: Data were collected through a qualitative study undertaken in three states (Anambra, Akwa-Ibom and Kano) in Nigeria. Respondents were formal/informal health providers, community leaders and representatives of civil society organizations all purposively sampled. There were 90 in-depth interviews and 12 focus group discussions, which were audio-recorded, transcribed verbatim and analysed thematically using codes to identify key themes. RESULTS: Factors constraining community health service delivery at the individual level were poor health-seeking behaviour, preference for quacks and male dominance of service delivery; at the community/facility level were superstitious/cultural beliefs and poor attitude of facility workers; at the governmental level were inadequate financial support, embezzlement of funds and inadequate social amenities. Conversely, the enabling factors at the individual level were community members' participation and the compassionate attitude of informal providers. At the community and facility levels, the factors that enhanced service delivery were synergy between formal and informal providers and support from community-based organizations and structures. At the governmental level, the enhancing factors were the government's support of community-based formal/informal providers and a clear line of communication. CONCLUSIONS: Community health service delivery through a functional community-health system can improve overall health systems strengthening and lead to improved community health. Policy-makers should integrate community health service delivery in all program implementation and ultimately work with the community health system as a veritable platform for effective community health service delivery.

Adolescent and youth-friendly health interventions in low-income and middle-income countries: a scoping review.

BACKGROUND: Adolescents comprise one-sixth of the world's population, yet there is no clear understanding of the features that promote adolescent-friendly services (AFS). The lack of clarity and consistency around a definition presents a gap in health services. METHODS: The review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. We conducted a scoping review of peer-reviewed empirical studies to explore AFS in low-income and middle-income countries (LMICs) published between January 2000 and December 2022. The databases searched were CAB Direct (n=11), CINAHL (n=50), Cochrane Databases (n=1103), Embase (n=1164), Global Health Medicus (n=3636) and PsycINFO (n=156). The title, abstract and full text were double screened by three independent reviewers. Three independent reviewers assessed the study's quality using the Joanna Briggs Initiative Quality Appraisal and Cochrane Risk of Bias 2 tools. RESULTS: We identified the key components, barriers and facilitators of AFS. The following emerged from our review: a non-judgmental environment, culturally appropriate and responsive interventions and a focus on supporting marginalised communities often living in high-poverty settings. Using these components, we have extended guidance around a possible framework and tool assessing quality of AFS. INTERPRETATION: As LMICs are heterogeneous and unique, it was assumed that the operational definition of 'adolescent-friendly' might vary depending on different contexts, but there must be core components that remain consistent. Possible limitations of our review include a lack of grey literature. Potential future implications include training healthcare providers, testing these attributes for service improvement and future development and localisation of policy guidelines. KEY HIGHLIGHTS: Our review has mapped the research framing of AFS and provided a comprehensive review of barriers and facilitators to implementing a holistic outlook of AFS set-up in a tightly controlled research and real-world context. Our paper is one of the few efforts to synthesise behavioural and mental health elements underpinning AFS.

Culture, community, and cancer: Understandings of breast cancer from a non-lived experience among women living in Soweto.

Background: Individual perceptions compounded with socio-cultural beliefs and health system factors are key determinants of people's health seeking behavior and are widely cited as the causes of delayed breast cancer diagnosis among women from structurally vulnerable settings. Asking: "how do women with a non-lived experience of cancer understand the disease and, what informs their health seeking behaviors?", we explored individual, sociocultural and health system elements from a conceptual model derived from the Socioecological, Health Belief and Cancer Stigma Frameworks, to understand perspectives of breast cancer in a South African urban community setting. Methods: Using a deductive approach, we conducted a qualitative study consisting of 6 focus group discussions among 34 women from Soweto, Johannesburg (aged 35-74 years) and followed-up with 20 semi-structured in-depth interviews. Results: Findings revealed some awareness of breast and other cancers, but confusion and gaps in understanding of the disease, resulting in socio-culturally influenced misperceptions of risks, causes, and outcomes following treatment of breast cancer. This fueled perceptions of profound fear and stigma against people with breast and other cancers. These findings together with participant perceptions of primary healthcare providers being unwelcoming, under-resourced, and insufficiently trained to deal with breast cancer, resulted in women reporting being reluctant to participating in screening/early detection care seeking behavior. They only accessed primary care when experiencing extreme pain or ill-health. Participants suggested as solutions for future interventions, the need for sustained community engagement, harnessing existing clinic and community stakeholders and resources to provide clear and understandable breast cancer information and encouragement for screening uptake. Conclusions: Health literacy gaps surrounding breast cancer fuels socio-culturally influenced misperceptions, fear, stigma, and fatalism among community women from Soweto, South Africa. Women perceive primary care providers of having insufficient knowledge, skills, and resources to provide effective breast cancer screening services. Participants suggested the need for greater community engagement involving primary clinics and existing community stakeholders working hand in hand. Clear, understandable, and consistent information about breast cancer must be regularly disseminated and communities must be regularly encouraged to utilise breast cancer screening services.

Quality of antenatal care services received by women of reproductive age prior to delivery in selected public health facilities in the northern zone of Ghana.

BACKGROUND: Over the past two decades, antenatal care (ANC) coverage has increased in most settings across low- and middle-income countries, including Ghana. However, evidence shows that there is a need to focus on both access and quality to improve maternal and newborn health outcomes. We investigated ANC quality among public healthcare facilities in the northern region of Ghana. METHODS: We conducted a facility-based study involving 420 postpartum women, selected randomly from five public health facilities. We collected information on a set of prenatal services that respondents self-reported to have received during their most recent pregnancy. Women who received all the interventions assessed were considered to have received quality ANC. Using multilevel (mixed-effects) regression analysis, we identified the independent factors associated with ANC quality, with healthcare facility as the cluster variable. RESULTS: Of the 420 women, 31.2% (95% CI: 26.9, 35.8) received ANC services of high quality. ANC quality differed significantly by women's background characteristics and ANC use. However, gestational age at first ANC and the number of follow-up visits before delivery were significantly associated with ANC quality: booking the first visit in the second or third trimester reduced the odds of receiving high-quality ANC compared to booking in the first trimester (aOR = 0.15, 95% CI: 0.07, 0.31, and aOR = 0.09, 95% CI: 0.01, 0.83, respectively). In contrast, achieving a minimum of eight ANC follow-ups before delivery increased the odds of receiving high-quality ANC compared to attaining fewer than eight visits (aOR = 4.82, 95% CI: 2.33, 9.99). CONCLUSIONS: A significant proportion of pregnant women in the study setting received suboptimal quality ANC during their most recent pregnancy. ANC quality was primarily associated with the timing of the first visit and the number of follow-up visits before delivery. Timely initiation of ANC and frequent follow-up visits will be crucial in the study's setting for pregnant women to benefit from comprehensive ANC services.

Achieving Robust Medical Coding in DRGs Systems: Innovative Actions Adopted in Greece.

The purpose of this study is to evaluate and illustrate the effectiveness of a specialized digital platform developed to improve the accuracy of medical coding during the full implementation of Greece's new DRG system, and to highlight innovative actions for achieving and/or improving accurate medical coding. Already grouped DRG cases recorded in the first DRG implementation year in the region of Crete were examined. A sample of 133,922 cases was analyzed and audited, through a process consisting of three stages: (i) digitalization, (ii) auditor training, and (iii) control and consultation. The results indicated that a significant proportion of DRG coding, with a length of stay exceeding one day, was reclassified into different DRG categories. This reclassification was primarily due to coding errors-such as the omission of secondary diagnoses, exclusion of necessary medical procedures, and the use of less specific codes-rather than mistakes in selecting the principal diagnosis. The study underscores the importance of medical coding control and consulting services. It demonstrates that targeted actions in these areas can significantly enhance the implementation of the DRG coding system. Accurate medical coding is crucial for transparent allocation of resources within hospitals, ensuring that hospital services and reimbursements are appropriately managed and allocated based on the true complexity and needs of patient cases.