Opportunities for Consistent and Holistic Metrics to Support Food Systems Transformation: A Summary of a Symposium Presented at Nutrition 2023.

There is an urgent need for global food systems transformation to realize a future where planetary health reaches its full potential. Paramount to this vision is the ability of stakeholders across sectors to understand how foods and dietary patterns impact food systems inclusive of all domains of sustainability-environmental, nutrition/health, economic and social. This article is a synopsis of presentations by 3 food systems experts to share the latest science in a session entitled "How do you measure sustainability? Opportunities for consistent and holistic metrics to support food systems transformation" at the American Society for Nutrition's 2023 annual conference. As summarized here, global population data showing widespread malnutrition underscore the important role of dietary diversity through a balance of plant- and animal-source foods to achieve nutritionally adequate diets and reduce risk of noncommunicable diseases. Yet, recent international audits of countries, companies, and organizations and their sustainability targets largely demonstrate an underrepresentation of robust nutrition/health metrics to support public nutrition and health progress. Addressing limitations in diet-sustainability modeling systems provides a viable opportunity to accurately reflect the important contributions and trade-offs of diets across all domains of sustainability to ultimately support evidence-based decision making in advancing healthy food systems.

Accountability in healthcare in the Netherlands: A scoping review.

For better serving people's complex needs the subsequent movement to person-centred integrated care, requires inter-organisational cooperation and service provision by domain-overarching networks and alliances. In the development to these networks, it is relevant to explore which accountability approaches are appropriate for local inter-organisational healthcare governance. Therefore, in a scoping review we studied the current state of knowledge and practice of accountability in healthcare in the Netherlands. We found that two of the included 41 studies show characteristics of accountability towards healthcare with characteristics of integration care components, such as integration of services with accompanying accountability arrangements and development of networked accountability. The first studies are found in the literature which report on accountability in integrated care. With this we add to the international discussion about accountability as an aspect of integrated care governance, by providing insight into the current state of art of accountability in Dutch healthcare.

Editors and Authors of Medical Journals Should Be Mindful of the New ICMJE Disclosure Form and Updated Policies.

The International Committee of Medical Journal Editors (ICMJE) recommendations are used by medical journals worldwide to guide editors and authors regarding "best practices" related to the intersection between research and publishing. In this opinion paper, we bring two discussion points to the attention of readers and users of the ICMJE recommendations. The first pertains to journals' use of the old conflicts of interest form, replaced in 2021 with a new disclosure form. The second relates to inconsistent or outdated policies in journals' instructions for authors mismatching the current ICMJE recommendations. The ICMJE does not monitor how journals use or apply the ICMJE recommendations. Thus, the editors must be mindful of updates and changes relevant to the authors. Furthermore, authors should carefully examine journals before submission to ensure that journals use updated forms and policies and should be mindful of submitting to non-ICMJE-recommendations-conforming journals despite claiming to follow them.

Piercing the veil on the functioning and effectiveness of district health system governance structures: perspectives from a South African province.

BACKGROUND: Leadership and governance are critical for achieving universal health coverage (UHC). In South Africa, aspirations for UHC are expressed through the proposed National Health Insurance (NHI) system, which underscores the importance of primary health care, delivered through the district health system (DHS). Consequently, the aim of this study was to determine the existence of legislated District Health Councils (DHCs) in Gauteng Province (GP), and the perceptions of council members on the functioning and effectiveness of these structures. METHODS: This was a mixed-methods, cross-sectional study in GP's five districts. The population of interest was members of existing governance structures who completed an electronic-self-administered questionnaire (SAQ). Using a seven-point Likert scale, the SAQ focuses on members' perceptions on the functioning and effectiveness of the governance structures. In-depth interviews with the chairpersons of the DHCs and its technical committees complemented the survey. STATA® 13 and thematic analysis were used to analyze the survey data and interviews respectively. RESULTS: Only three districts had constituted DHCs. The survey response rate was 73%. The mean score for perceived functioning of the structures was 4.5 (SD = 0.7) and 4.8. (SD = 0.7) for perceived effectiveness. The interviews found that a collaborative district health development approach facilitated governance. In contrast, fraught inter-governmental relations fueled by the complexity of governing across two spheres of government, political differences, and contestations over limited resources constrained DHS governance. Both the survey and interviews identified gaps in accountability to communities. CONCLUSION: In light of South Africa's move toward NHI, strengthening DHS governance is imperative. The governance gaps identified need to be addressed to ensure support for the implementation of UHC reforms.

The MULTI-ACT model: the path forward for participatory and anticipatory governance in health research and care.

The COVID-19 pandemic has unmasked even more clearly the need for research and care to form a unique and interdependent ecosystem, a concept which has emerged in recent years. In fact, to address urgent and unexpected missions such as "fighting all together the COVID-19 pandemic", the importance of multi-stakeholder collaboration, mission-oriented governance and flexibility has been demonstrated with great efficacy. This calls for a policy integration strategy and implementation of responsible research and innovation principles in health, promoting an effective cooperation between science and society towards a shared mission. This article describes the MULTI-ACT framework and discusses how its innovative approach, encompassing governance criteria, patient engagement and multidisciplinary impact assessment, represents a holistic management model for structuring responsible research and innovation participatory governance in brain conditions research.

An evaluation of community placements for GP registrars in Yorkshire and the Humber: 'a home visit not to a patient but to the community'.

BACKGROUND: GP registrars are required to demonstrate capabilities in 'community orientation', reflecting skills in developing and working with services that respond to community needs. These skills have sometimes been seen as vague and difficult to obtain. In the Yorkshire and the Humber Deanery of Health Education England we developed a novel programme of community placements to overcome this. Registrars spent two half-days with a community organisation of their choosing, working in their practice area. AIM: To evaluate if and how community placements enabled registrars to develop capabilities in community orientation. METHODS: All registrars completing placements were invited to participate in the evaluation; 13 (7%) accepted. Semi-structured, face-to-face and telephone interviews explored registrars' perceptions and experiences of the programme. Interviews were audio-recorded, transcribed verbatim and analysed thematically. RESULTS: The majority of participants reported that placements enabled them to attain a range of capabilities in community orientation. Registrars described an improved understanding of their practice community and the social determinants of health. Placements impacted their clinical practice by stimulating a holistic approach to the assessment and management of health needs. Our analysis described five key mechanisms for this learning: building confidence, building communities and networks of practice, gaining novel perspectives, generating a hunger for general practice and experiential learning. CONCLUSION: Community placements enabled GP registrars to attain capabilities in community orientation. Further research is required to determine the transferability of our findings and further evaluate mechanisms of learning through placements outside of training and their role in the development of professional practice.

The benefits of an innovative community engagement model in dental undergraduate education.

Dental healthcare students at the Peninsula Dental School, University of Plymouth, UK undertake community engagement projects as a core part of their undergraduate curriculum. Students work with their peers to develop a student-led, evidence-based project working with target groups in the local community to address oral health needs. The aim of the programme is to further the students' understanding of health inequalities and the health needs of different groups in the community, while developing skills that will help them deliver holistic dental care as part of their future professional practice. This report highlights our model of education delivery in collaboration with the community, the student-learning outcomes and discusses some of the benefits of this approach including examples of projects that have benefitted the community. We highlight the further work needed to evaluate the longer-term impacts on students of undertaking social accountability programmes.

Prescribing practice: an overview of the principles.

Nurse prescribing has become a well-established aspect of advanced clinical practice working alongside key NHS principles and drivers to address the increasing complexities in patient care and the demands on the health service. Prescribing practice is governed by ethical and legal principles to ensure a holistic patient-centred approach. It has been recognised as a valuable resource that could effectively transform healthcare services to reduce hospital admissions and long hospital stays and improve the quality of life for patients with long-term conditions and multiple comorbidities. This article will provide an overview of prescribing practice.

Unknown unknowns: can bringing patients' lived experience of long term conditions into curriculum design help our future doctors offer more holistic, socially accountable care?

Understanding the holistic impact of long-term conditions (LTCs) on a patient, due to their high prevalence, morbidity, mortality and cost, is an important part of the primary care undergraduate medicine curriculum. Increasingly, we set learning outcomes for our students anticipating what the patient would want them to know. But are our expectations congruent with what patients would want them to know? In this leading article, we propose that patient involvement in curriculum design remains inadequate. We base our argument on (1) an existing strong theoretical premise that increasing patient incorporation enhances the delivery of medical education, (2) recommendations from major health organisations, our regulator and leading healthcare educationalists and (3) a growing body of evidence that what is important to physicians may not reflect what is important to patients. We advocate that patient involvement in curriculum design will result in a better understanding of how LTCs affect their physical, psychological and social health and of their journey through health care and community support services. This learning is essential, but unfortunately often overlooked, if we are to ensure that students in their future roles plan patient care using an empathic, holistic, patient-centred and socially accountable approach.

The continuing role of communities affected by HIV in sustained engagement in health and rights.

INTRODUCTION: The meaningful involvement of persons affected by a disease is a unique aspect of the HIV response that places people living with (PLHIV) and those directly affected by HIV (peers) at the centre of the design, development and implementation of service delivery and research and policy making. The principle of greater involvement of PLHIV (GIPA) has and will increasingly ensure equitable access to services and engagement of marginalized groups in the HIV response, and to health services more broadly. This paper describes the history, current place in the HIV response and potential future role of PLHIV and communities in health responses. DISCUSSION: Historically, the role of communities of PLHIV and peers in service delivery, research and drug development, advocacy, social and political accountability, resource mobilization and social and human rights protection is well documented. Their leadership and engagement have contributed directly to improved outcomes in access to HIV treatment, prevention, support and care services around the world. Their continued and expanded role is especially important for the future success of HIV responses in sub-Saharan Africa, where the HIV burden remains the greatest. The lessons learned from the leadership and involvement of communities of PLHIV and peers in the HIV response hold value beyond HIV responses. The models and approaches they have efficiently and effectively utilized have relevant applications in addressing shortfalls in health systems in the COVID-19 era, as well as broader, more integrated health challenges as countries move to develop and operationalize universal health coverage (UHC). However, neither HIV nor other health and development targets can be met if their contributions are not adequately recognized, valued and funded. CONCLUSIONS: The past three decades have demonstrated that communities of PLHIV and their peers are instrumental in sustaining engagement and advocacy for health equity and financing for health and ensuring that the human rights of all people are recognized and upheld. Quality and effective integration of health systems and UHC can be more effectively designed, implemented and sustained with communities of PLHIV and peers at the centre.

Influence of community scorecards on maternal and newborn health service delivery and utilization.

INTRODUCTION: The community score card (CSC) is a participatory monitoring and evaluation tool that has been employed to strengthen the mutual accountability of health system and community actors. In this paper we describe the influence of the CSC on selected maternal and newborn service delivery and utilization indicators. METHODS: This was a mixed methods study that used both quantitative and qualitative data collection methods. It was implemented in five sub-counties and one town council in Kibuku district in Uganda. Data was collected through 17 key informant interviews and 10 focus group discussions as well as CSC scoring and stakeholder meeting reports. The repeated measures ANOVA test was used to test for statistical significance. Qualitative data was analyzed manually using content analysis. The analysis about the change pathways was guided by the Wild and Harris dimensions of change framework. RESULTS: There was an overall improvement in the common indicators across sub-counties in the project area between the 1st and 5th round scores. Almost all the red scores had changed to green or yellow by round five except for availability of drugs and mothers attending Antenatal care (ANC) in the first trimester. There were statistically significant differences in mean scores for men escorting their wives for ante natal care (ANC) (F(4,20) = 5.45, P = 0.01), availability of midwives (F(4,16) =5.77, P < 0.01), availability of delivery beds (F(4,12) =9.00, P < 0.01) and mothers delivering from traditional birth attendants (TBAs), F(4,16) = 3.86, p = 0.02). The qualitative findings suggest that strengthening of citizens' demand, availability of resources through collaborative problem solving, increased awareness about targeted maternal health services and increased top down performance pressure contributed to positive changes as perceived by community members and their leaders. CONCLUSIONS AND RECOMMENDATIONS: The community score cards created opportunities for community leaders and communities to work together to identify innovative ways of dealing with the health service delivery and utilization challenges that they face. Local leaders should encourage the availability of safe spaces for dialogue between communities, health workers and leaders where performance and utilization challenges can be identified and solutions proposed and implemented jointly.

Can people-centered community-oriented interventions improve skilled birth attendance? Evidence from a quasi-experimental study in rural communities of Cambodia, Kenya, and Zambia.

BACKGROUND: Skilled attendance at delivery is a key marker for reducing maternal mortality. Effective community engagement strategies complemented by community health worker (CHW) services can improve access to maternal health services in areas with limited health infrastructure or workforce. METHODS: A quasi-experimental study with matched comparison groups was conducted in Cambodia, Kenya and Zambia to determine the effect of integrated community investments on skilled birth attendance (SBA). In each country, communities in two districts/sub-districts received a package of community-oriented interventions comprised of timed CHW household health promotion for maternal, newborn and child health complemented by social accountability mechanisms using community scorecards. Two matched comparison districts/sub-districts received ongoing routine interventions. Data from the final evaluation were examined to determine the effect of timed CHW services and community-oriented interventions on SBA. RESULTS: Over 80% of the 3037 women in Cambodia, 2805 women in Kenya and 1171 women in Zambia reported SBA. Women in intervention sites who received timely CHW health promotion and social accountability mechanisms in Cambodia showed significantly higher odds of SBA (aOR = 7.48; 95% CI: 3.87, 14.5). The findings also indicated that women over the age of 24 in Cambodia, women with primary or secondary education in Cambodia and secondary education in Kenya, women from higher wealth quintiles in Cambodia, and women with four or more antenatal care (ANC) visits in all countries reported significantly higher odds of SBA. Inclusion of family members in pregnancy-related discussions in Kenya (aOR = 2.12; 95% CI: 1.06, 4.26) and Zambia (aOR = 6.78; 95% CI: 1.15, 13.9) and follow up CHW visits after a referral or health facility visit (aOR = 2.44; 95% CI: 1.30, 4.60 in Cambodia; aOR = 2.17; 95% CI 1.25, 3.75 in Kenya; aOR = 1.89; 95% CI: 1.05, 2.02 in Zambia) also showed significantly greater odds of SBA. CONCLUSIONS: Enhancing people-centered care through culturally appropriate community-oriented strategies integrating timely CHW health promotion and social accountability mechanisms shows some evidence for improving SBA during delivery. These strategies can accelerate the achievement of the sustainable development goals for maternal child and newborn health.

Decision-making in an emergency department: A nursing accountability model.

INTRODUCTION: Nurses who work in an emergency department regularly care for acute patients in a fast-paced environment, being at risk of suffering high levels of burnout. This situation makes them especially vulnerable to be accountable for decisions they did not have time to consider or have been pressured into. RESEARCH OBJECTIVE: The objective of this study was to find which factors influence ethical, legal and professional accountability in nursing practice in an emergency department. RESEARCH DESIGN: Data were analysed, codified and triangulated using qualitative ethnographic content analysis. PARTICIPANTS AND RESEARCH CONTEXT: This research is set in a large emergency department in the Midlands area of England. Data were collected from 186 nurses using participant observation, 34 semi-structured interviews with nurses and ethical analysis of 54 applicable clinical policies. ETHICAL CONSIDERATIONS: Ethical approval was granted by two research ethics committees and the National Health Service Health Research Authority. RESULTS: The main result was the clinical nursing accountability cycle model, which showed accountability as a subjective concept that flows between the nurse and the healthcare institution. Moreover, the relations among the clinical nursing accountability factors are also analysed to understand which factors affect decision-making. DISCUSSION: The retrospective understanding of the factors that regulate nursing accountability is essential to promote that both the nurse and the healthcare institution take responsibility not only for the direct consequences of their actions but also for the indirect consequences derived from previous decisions. CONCLUSION: The decision-making process and the accountability linked to it are affected by several factors that represent the holistic nature of both entities, which are organised and interconnected in a complex grid. This pragmatic interpretation of nursing accountability allows the nurse to comprehend how their decisions are affected, while the healthcare institution could act proactively to avoid any problems before they happen.

Development of a national conceptual framework and measuring tool for Organisational Social Responsibility and Accountability for Health (OSRAH).

Organisations can have a significant impact (positive or negative) on society through their actions and decisions. Given this reality, it is important that they are held responsible and accountable for the consequences of their actions. This concept is often referred to as 'social responsibility'. However, 'social responsibility', as currently conceived in the literature, neglects a specific focus on health as a social goal. Additionally, there are no practical tools to capture this concept in a holistic way to facilitate implementation and monitoring of organisational improvement. This paper reports on the process of developing a more holistic conceptual framework and tool for assessing organisational social responsibility and accountability for health (OSRAH). We conducted a review of the published and grey literature and engaged in expert consultation and focus group discussions. The initial OSRAH framework and the self-assessment tool were finalised for implementation and used by 95 organisations at a national event in Iran in February 2017. The results of the assessment data collected at the event showed organisations scored lowest in the domain of community health and highest in the domain of employee health. The OSRAH framework and assessment tool represents a new understanding of health and its determinants in organisations outside the health sector. It integrates health within the existing Corporate Social Responsibility (CSR) culture of organisations. The process of creating the tool and implementing it at the national festival of OSRAH in Iran created momentum for intersectoral action. This experience can inspire researchers and practitioners in other countries, especially in developing countries, to develop their own local definition and practical assessment framework for responsibility and accountability.

The relevance of nurses and midwives code of conduct in Australia.

AIM: This study explores Australian clinical nurses' and midwives' familiarity with a new code of conduct and understanding in what ways the code is important for nurses as they carry out clinical practice. BACKGROUND: Codes specify the expectations of nurses' responsibilities, legal requirements, behaviour and conduct. Being familiar with the code is central to being a professional nurse or midwife. As nursing continues to advance, updating the code is crucial to maintain professional and safe practice. DESIGN: This project utilized a cross-sectional descriptive design. METHODS: A survey was developed incorporating Likert-type scale assessments of the 7 value statements from the 2018 Australian Nurses' Code of Conduct for familiarity and importance. The survey included open-ended questions to elicit clinical nurses' experiences of conduct breaches, opinions regarding usefulness and relevance of the code for current practice. Data were collected at an acute care hospital in Sydney during January 2018. RESULTS: Significant differences relating to cultural and patient-centred approaches were revealed in the study. The new value involving the role of research was least understood and ranked least important by nurses and midwives. Professional 'integrity' resonated with participants when considering the behaviour of nurses, and short, unambiguous values were the most popular. Additionally, a substantial number of participants had no knowledge of the code or were not aware of the recently revised version. CONCLUSION AND IMPLICATIONS FOR NURSING: A code of conduct provides structure and guidance for workplace values and principles. A respected code is important to the nursing profession to help prevent inappropriate and incompetent behaviour and as a guide for nursing performance. Nurses in this study claimed the code was highly relevant to their work as a nurse and was incorporated into their daily practice.

Patient experience feedback in UK hospitals: What types are available and what are their potential roles in quality improvement (QI)?

BACKGROUND & OBJECTIVES: The comparative uses of different types of patient experience (PE) feedback as data within quality improvement (QI) are poorly understood. This paper reviews what types are currently available and categorizes them by their characteristics in order to better understand their roles in QI. METHODS: A scoping review of types of feedback currently available to hospital staff in the UK was undertaken. This comprised academic database searches for "measures of PE outcomes" (2000-2016), and grey literature and websites for all types of "PE feedback" potentially available (2005-2016). Through an iterative consensus process, we developed a list of characteristics and used this to present categories of similar types. MAIN RESULTS: The scoping review returned 37 feedback types. A list of 12 characteristics was developed and applied, enabling identification of 4 categories that help understand potential use within QI-(1) Hospital-initiated (validated) quantitative surveys: for example the NHS Adult Inpatient Survey; (2) Patient-initiated qualitative feedback: for example complaints or twitter comments; (3) Hospital-initiated qualitative feedback: for example Experience Based Co-Design; (4) Other: for example Friends & Family Test. Of those routinely collected, few elicit "ready-to-use" data and those that do elicit data most suitable for measuring accountability, not for informing ward-based improvement. Guidance does exist for linking collection of feedback to QI for some feedback types in Category 3 but these types  are not routinely used. CONCLUSION: If feedback is to be used more frequently within QI, more attention must be paid to obtaining and making available the most appropriate types.

Who Needs Big Health Sector Reforms Anyway? Seychelles' Road to UHC Provides Lessons for Sub-Saharan Africa and Island Nations.

The road to universal health coverage (UHC) needs not be driven by big reforms that include the initiation of health insurance, provider-funder separation, results-based financing, or other large health sector reforms advocated in many countries in sub-Saharan Africa and elsewhere. The Seychelles experience, documented through a series of analytical products like public expenditure reviews and supporting surveys with assistance from the World Bank and World Health Organization (WHO), shows an alternative, more incremental reform road to UHC, with important lessons to the region and other small-population or island nations. Done well, in some countries, a basic supply-side funded, publicly owned and operated, and integrated health system can produce excellent health outcomes in a cost-effective and sustainable way. The article traces some of the factors that facilitated this success in the Seychelles, including high political commitment, strong voice and a downward accountability culture, strong public health functions, and an impressive investment in primary health care. These factors help explain past successes and also provide a good basis for adaptation of health systems to dramatic shifts in the epidemiological and demographic transitions, disease outbreaks, and rising public expectation and demand for high quality of care. Once again, how the Seychelles responds can show the way for other countries in the region and elsewhere regardless of the types of reforms countries engage in.

The development of a global Midwifery Education Accreditation Programme.

BACKGROUND: Many countries are responding to the global shortage of midwives by increasing the student intake to their midwifery schools. At the same time, attention must be paid to the quality of education being provided, so that quality of midwifery care can be assured. Methods of assuring quality of education include accreditation schemes, but capacity to implement such schemes is weak in many countries. OBJECTIVE: This paper describes the process of developing and pilot testing the International Confederation of Midwives' Midwifery Education Accreditation Programme (ICM MEAP), based on global standards for midwifery education, and discusses the potential contribution it can make to building capacity and improving quality of care for mothers and their newborns. METHODS: A review of relevant global, regional and national standards and tools informed the development of a set of assessment criteria (which was validated during an international consultation exercise) and a process for applying these criteria to midwifery schools. The process was pilot tested in two countries: Comoros and Trinidad and Tobago. RESULTS: The assessment criteria and accreditation process were found to be appropriate in both country contexts, but both were refined after the pilot to make them more user-friendly. CONCLUSION: The ICM MEAP has the potential to contribute to improving health outcomes for women and newborns by building institutional capacity for the provision of high-quality midwifery education and thus improved quality of midwifery care, via improved accountability for the quality of midwifery education.

A critique of the Uganda district league table using a normative health system performance assessment framework.

BACKGROUND: In 2003 the Uganda Ministry of Health (MoH) introduced the District League Table (DLT) to track district performance. This review of the DLT is intended to add to the evidence base on Health Systems Performance Assessment (HSPA) globally, with emphasis on Low and Middle Income Countries (LMICs), and provide recommendations for adjustments to the current Ugandan reality. METHODS: A normative HSPA framework was used to inform the development of a Key Informant Interview (KII) tool. Thirty Key Informants were interviewed, purposively selected from the Ugandan health system on the basis of having developed or used the DLT. KII data and information from published and grey literature on the Uganda health system was analyzed using deductive analysis. RESULTS: Stakeholder involvement in the development of the DLT was limited, including MoH officials and development partners, and a few district technical managers. Uganda policy documents articulate a conceptually broad health system whereas the DLT focuses on a healthcare system. The complexity and dynamism of the Uganda health system was insufficiently acknowledged by the HSPA framework. Though DLT objectives and indicators were articulated, there was no conceptual reference model and lack of clarity on the constitutive dimensions. The DLT mechanisms for change were not explicit. The DLT compared markedly different districts and did not identify factors behind observed performance. Uganda lacks a designated institutional unit for the analysis and presentation of HSPA data, and there are challenges in data quality and range. CONCLUSIONS: The critique of the DLT using a normative model supported the development of recommendation for Uganda district HSPA and provides lessons for other LMICs. A similar approach can be used by researchers and policy makers elsewhere for the review and development of other frameworks. Adjustments in Uganda district HSPA should consider: wider stakeholder involvement with more district managers including political, administrative and technical; better anchoring within the national health system framework; integration of the notion of complexity in the design of the framework; and emphasis on facilitating district decision-making and learning. There is need to improve data quality and range and additional approaches for data analysis and presentation.