Salve Lucrum: The Existential Threat of Greed in US Health Care.

In this Viewpoint, Donald Berwick explores the pursuit of profit in US health care across sectors­such as pharmaceutical companies, insurers, hospitals, and physician practices­and its harms to patients, and then offers potential solutions.

Manifestations, responses, and consequences of mistreatment of sick newborns and young infants and their parents in health facilities in Kenya.

BACKGROUND: Despite efforts to incorporate experience of care for women and newborns in global quality standards, there are limited efforts to understand experience of care for sick newborns and young infants. This paper describes the manifestations, responses, and consequences of mistreatment of sick young infants (SYIs), drivers, and parental responses in hospital settings in Kenya. METHODS: A qualitative formative study to inform the development of strategies for promoting family engagement and respectful care of SYI was conducted in five facilities in Kenya. Data were collected from in-depth interviews with providers and policy makers (n = 35) and parents (n = 25), focus group discussions with women and men (n = 12 groups), and ethnographic observations in each hospital (n = 64 observation sessions). Transcribed data were organized using Nvivo 12 software and analyzed thematically. RESULTS: We identified 5 categories of mistreatment: 1) health system conditions and constraints, including a) failure to meet professional standards, b) delayed provision of care; and c) limited provider skills; 2) stigma and discrimination, due to provider perception of personal hygiene or medical condition, and patient feelings of abandonment; 3) physically inappropriate care, including providers taking blood samples and inserting intravenous lines and nasogastric tubes in a rough manner; or parents being pressured to forcefully feed infants or share unsterile feeding cups to avoid providers' anger; 4) poor parental-provider rapport, expressed as ineffective communication, verbal abuse, perceived disinterest, and non-consented care; and 5) no organized form of bereavement and posthumous care in the case of infant's death. Parental responses to mistreatment were acquiescent or non-confrontational and included feeling humiliated or accepting the situation. Assertive responses were rare but included articulating disappointment by expressing anger, and/or deciding to seek care elsewhere. CONCLUSION: Mistreatment for SYIs is linked to poor quality of care. To address mistreatment in SYI, interventions that focus on building better communication, responding to the developmental needs of infants and emotional needs for parents, strengthen providers competencies in newborn care, as well as a supportive, enabling environments, will lead to more respectful quality care for newborns and young infants.

Diversity in health care institutions reduces Israeli patients' prejudice toward Arabs.

Diversity in the lines of public institutions, such as hospitals, schools, and police forces, is thought to improve provision for minority group members. Nonetheless, whether and how diversity in public institutions shapes majority citizens' prejudice toward minorities are unclear. Building on insights from the intergroup contact literature, I suggest that diversity in public institutions can facilitate positive intergroup contact between majority group members and minorities in elevated social positions. Such unique interactions, which exceed the equal status condition for effective intergroup contact, can serve to reduce prejudice and facilitate more inclusive attitudes among majority group members. To test this expectation, I focus on health care provision-a leading sector with regard to minority representation. Leveraging a natural experiment unfolding in 21 Israeli medical clinics where Jewish patients are haphazardly assigned to receive care from Jewish or Arab doctors and embedding prejudice-related questions in a routine evaluation survey, I demonstrate that brief contact with an Arab doctor reduces prejudice. Specifically, contact with an Arab doctor reduces Jewish patients' exclusionary preferences toward Arabs by one-sixth of an SD and increases Jewish patients' optimism about peace by a 10th of an SD. The modest magnitude of these effects is similar to the impact of well-powered interventions recently reviewed in a meta-analysis of prejudice reduction experiments. These findings emphasize how the demographic makeup of public institutions can reduce mass prejudice, even in a context of intractable conflict.

Authentic and ethical leadership during a crisis.

In today's climate and environment, the conventional relationship between caring, economic, and leadership practices may no longer meet the needs of patients, clinicians, providers, or systems. It is asserted that in the current complicated and complex healthcare environment challenged by a multitude of issues, a shift toward human caring values and an ethic of authentic healing relationships is required, especially in light of the current COVID-19 pandemic. The costs of unethical behaviour can be even greater for followers. When we assume the benefits of leadership, we also assume ethical burdens. It is the assertion and experience of the authors that the triangle of ethics and ethical behaviour, followers, and patient outcomes is closely interrelated and affects each other in a very intimate and direct way. Unethical leadership may lead to follower disappointment and distrust, leading to lack of interest and commitment, consequently negatively impacting patient outcomes and organizational effectiveness.

An ethical approach to considering family presence during COVID-19.

The COVID-19 pandemic has required healthcare organizations to introduce risk mitigation strategies that challenge usual family presence (visitor) policies. Policies within healthcare must be viewed from an ethical lens, which includes ensuring that the patient voice helps guide decision-making. In considering pandemic-specific family presence policies, Kingston Health Sciences Centre, an academic tertiary care hospital in Southeastern Ontario, applied an ethical framework for decision-making. The various tensions between the values of duty to provide care, protection of the public from harm, transparency, proportionality, and patient-centred care are highlighted in a discussion of how patient partners contributed to decision-making about family presence in the first 9 months of the COVID-19 pandemic.

Disrespect and Abuse during Childbirth in Ethiopia: A Systematic Review.

BACKGROUND: Disrespect and abuse are recognized for the restricting impact of women from seeking maternal care, psychological humiliations, grievances, and unspoken sufferings on women during childbirth. Individual primary studies are limited in explaining of extent of disrespect and abusive care. Hence, this review considers the synthesis of comprehensive evidence on the extent, contributing factors, and consequences of disrespectful and abusive intrapartum care from the women's and providers' perspectives in Ethiopia. METHODS: Articles had been systematically searched from the databases of PubMed, Cochrane Library, POPLINE, Google Scholar, HINARI, African Journals Online, and WHO Global Health Library. A qualitative and quantitative synthesis was performed using the Bowser and Hill landscape analytical framework. RESULT: Twenty-two studies comprised of the 16 quantitative; 5 qualitative and one mixed studies were included. The most repeatedly dishonored right during facility-based childbirth in Ethiopia was nondignified care, and the least commonly reported abuse was detention in health facilities. These behaviors were contributed by normalization of care, lack of empowerment and education of women, weak health system, and lack of training of providers. Women subjected to disrespectful and abusive behavior distanced themselves from the use of facility-based childbirth-related services and have endured psychological humiliations. CONCLUSION: Disrespectful and abusive care of women during childbirth is repeatedly practiced care in Ethiopia. This result specifically described the contributing factors and their effects as a barrier to the utilization of facility-based childbirth. Therefore, to overcome this alarming problem, health systems and care providers must be responsive to the specific needs of women during childbirth, and implementing policies for standard care of respectful maternity care must be compulsory. In addition, observational, qualitative, and mixed types of studies are required to provide comprehensive evidences on disrespect and abusive behavior during childbirth in Ethiopia.

Ethical Considerations for Healthcare Organizations.

Ethical misbehavior in the delivery of healthcare creates harm not only to individual therapists and administrators who might choose to overstep ethical boundaries but also, more broadly, causes harm to patients, to healthcare organizations, to professional organizations, and ultimately to society. Both corporate codes of conduct and professional codes of ethics are important, because they set standards of conduct and penalize noncompliant or unethical conduct. The purposes of this article are (1) to differentiate corporate compliance from ethics in a healthcare organization; (2) to explain the application of ethics principles to organizational and professional behaviors; (3) to discuss three important ethical issues (cultural competence, conflict of interest, and employer demands); and (4) to emphasize that, whether applying a corporate code of conduct or a professional code of ethics (or both), the integrity of each individual is essential to ethical behavior. To illustrate these concepts, ASHA's Code of Ethics is discussed in detail (including the ethics complaint adjudication process), and hypothetical case studies are presented under the macro headings of Cultural Competence, Conflict of Interest, and Employer Demands.

How Should Clinicians Respond to International Public Health Emergencies?

This case analysis examines obligations health care workers have to support relief efforts when an infectious disease outbreak could impact us all. How clinicians, institutions, and local communities ought to balance increased need for global solidarity in response to global disease outbreaks with concerns of local stakeholders is one specific tension this article investigates. We explore how emphasizing global health solidarity in the face of highly hazardous communicable diseases can help mitigate global risk.

The pop-up research centre - Challenges and opportunities.

OBJECTIVES: This article sets out to describe the concept of the "pop-up" research centre as a means to promote and develop radiography research locally, nationally and internationally, and to empower professional colleagues to set up similar initiatives in the future. KEY FINDINGS: A detailed overview of the development and management of "pop-up" research is provided based on the experiences of the authors, including specific examples. Matters such as study design, approvals, equipment and software, environment, participant recruitment and management, research teams and activity costs are discussed. Quantifiable benefits of "pop-up" research such as resultant peer reviewed publications, development of researchers' skills and potential collaborations are described. A number of "soft skill" benefits are also apparent and include enhanced organisational profiles, team building and the development of leadership skills. CONCLUSIONS: "Pop-up" research centres are a valuable option for conducting research and offer the radiography profession an achievable mechanism to increase and enhance research activity. However, careful planning and execution are essential.

Ultrasound in rural India: a failure of the best intentions.

The Pre-Conception and Pre-Natal Diagnostic Techniques Act was written to prevent societally unacceptable harms including intentional sex selection. The pragmatism required to enforce this law has profound effects on the ability of rural Indians to access diagnostic ultrasonography. In so doing, it may have inadvertently placed a heavier burden on the poorest and worsened health inequity in India, creating serious ethical and justice concerns. It is time to re-examine and update the law such that diagnostic ultrasonography is widely available in even the most peripheral primary health and community health centres. Shorter, more accessible ultrasonography training courses should be offered; collaboration between radiologists and rural practitioners and facilities should be encouraged. Finally, modern ultrasound machines can carefully record all images via a "silent observer" modality. With some modifications to previously used silent observer modalities, this technology allows both greater access and better policing of potential misuse of ultrasound technology.

Hospitais seguros frente a desastres: tradução e aproximação cultural do Indice de Seguridad Hospitalaria para o contexto brasileiro / Hospitals safe from disasters: translation and cultural adaptation of the Hospital Safety Index for the Brazilian context

O funcionamento ininterrupto do estabelecimento de saúde, em especial depois de ocorrido um desastre, marca a diferença entre a vida e a morte, ensejando que as estruturas física, operacional e funcional, além dos equipamentos da unidade assistencial, mostrem-se resistentes aos efeitos dos desastres. Nesse contexto, destaca-se como um importante instrumento de avaliação e de gestão de risco de desastres o Indice de Seguridad Hospitalaria (ISH), proposto pela Organização Pan-americana de Saúde (OPAS) em 2008, originalmente em idioma espanhol. No Brasil, apesar de os desastres, principalmente os de causas naturais, estarem ocorrendo com maior frequência nos últimos anos, ainda não há, no cenário nacional, a versão do citado instrumento de avaliação traduzida e adaptada culturalmente, de maneira que não há como mensurar, efetivamente, o preparo de unidades de saúde brasileiras para se manterem funcionando na vigência de um desastre. Objetivos: traduzir para o idioma português do Brasil o instrumento de análise do Indice de Seguridad Hospitalaria, e realizar a aproximação cultural desse instrumento para o contexto brasileiro. Método: estudo metodológico desenvolvido através das etapas de tradução, síntese da tradução, retro tradução e análise de compreensão por comitê de especialistas, compondo, ao final do processo, a versão traduzida consensual do ISH. Os aspectos éticos da pesquisa foram atendidos, respeitando a Resolução nº 466/2012. O estudo foi aprovado pelo Comitê de Ética e Pesquisa da Escola de Enfermagem Anna Nery, sob o 69438217.5.0000.5238, em 11 de julho de 2017. Resultados: seguindo as etapas metodológicas, o estudo apresenta o Indice de Seguridad Hospitalaria traduzido para o idioma português do Brasil e adaptado culturalmente para aplicação nos estabelecimentos de saúde brasileiros. A análise dos itens avaliados no ISH permite estabelecer a proporção entre eles, revelando que 9% do formulário referem-se a questões relativas à parte estrutural, 49% das questões são referentes à parte não estrutural e 42% do formulário avaliam aspectos ligados à área funcional. Tais proporções reafirmam a importante característica do ISH como instrumento com uma proposta dinâmica, integrada e interdisciplinar de avaliação, onde questões ligadas à funcionalidade e linhas vitais do hospital perfazem 91% das vulnerabilidades consideradas. Conclusão: o processo de tradução e análise de equivalências é o passo inicial para possibilitar a disponibilização de um instrumento que 9 avalie, de maneira sistemática e confiável no Brasil, o preparo dos hospitais para se manterem em adequado funcionamento na vigência de desastres. O estudo, além de considerar os aspectos metodológicos pertinentes para a tradução e adaptação cultural do ISH para o contexto brasileiro, reconhece as limitações do ISH e a necessidade das reflexões e debates acerca da multidimensionalidade dos desastres, revelando aspectos relacionados à importância da interdisciplinaridade para a gestão de riscos neste cenário, onde diversos profissionais são indispensáveis, integram-se e interagem com o propósito de planejar ações e salvar vidas, destacando-se, neste tocante, a enfermagem por sua visão abrangente, sensível e diferenciada. Por fim, o estudo aborda o tema hospitais seguros proposto pela OPAS em uma análise contextualizada, considerando os enfoques humanos e sociais desencadeadores e resultantes dos desastres em sua ampla concepção.(AU)

Why some women fail to give birth at health facilities: A comparative study between Ethiopia and Nigeria.

BACKGROUND: Obstetric complications and maternal deaths can be prevented through safe delivery process. Facility based delivery significantly reduces maternal mortality by increasing women's access to skilled personnel attendance. However, in sub-Saharan Africa, most deliveries take place without skilled attendants and outside health facilities. Utilization of facility-based delivery is affected by socio-cultural norms and several other factors including cost, long distance, accessibility and availability of quality services. This study examined country-level variations of the self-reported causes of not choosing to deliver at a health facility. METHODS: Cross-sectional data on 37,086 community dwelling women aged between 15-49 years were collected from DHS surveys in Ethiopia (n = 13,053) and Nigeria (n = 24,033). Outcome variables were the self-reported causes of not delivering at health facilities which were regressed against selected sociodemographic and community level determinants. In total eight items complaints were identified for non-use of facility delivery: 1) Cost too much 2) Facility not open, 3) Too far/no transport, 4) don't trust facility/poor service, 5) No female provider, 6) Husband/family didn't allow, 7) Not necessary, 8) Not customary. Multivariable regression methods were used for measuring the associations. RESULTS: In both countries a large proportion of the women mentioned facility delivery as not necessary, 54.9% (52.3-57.9) in Nigeria and 45.4% (42.0-47.5) in Ethiopia. Significant urban-rural variations were observed in the prevalence of the self-reported causes of non-utilisation. Women in the rural areas are more likely to report delivering at health facility as not customary/not necessary and healthy facility too far/no transport. However, urban women were more likely to complain that husband/family did not allow and that the costs were too high. CONCLUSION: Women in the rural were more likely to regard facility delivery as unnecessary and complain about transportation and financial difficulties. In order to achieving the maternal mortality related targets, addressing regional disparities in accessing maternal healthcare services should be regarded as a priority of health promotion programs in Nigeria and Ethiopia.

Ethical Guidance for Selecting Clinical Trials to Receive Limited Space in an Immunotherapy Production Facility.

Our aims are to (1) set forth a multiprinciple system for selecting among clinical trials competing for limited space in an immunotherapy production facility that supplies products under investigation by scientific investigators; (2) defend this system by appealing to justice principles; and (3) illustrate our proposal by showing how it might be implemented. Our overarching aim is to assist manufacturers of immunotherapeutic products and other potentially breakthrough experimental therapies with the ethical task of prioritizing requests from scientific investigators when production capacity is limited.

Política antimicrobiana. Necesidad imperiosa ante la creciente resistencia microbiana actual / Antimicrobial policy. Imperative need in view of the current increasing microbial resistance

Introducción: Los antimicrobianos constituyen uno de los grupos farmacológicos más utilizados en la práctica clínica y está demostrada su relación con la resistencia microbiana. El uso racional de antibióticos puede producir beneficios desde el punto de vista médico y social, pero su uso en ocasiones no es el más adecuado y debe ser objeto de una vigilancia especial y sistemática. Es necesaria una política antimicrobiana coherente en las unidades de salud. Objetivo: Revisar consensos y criterios nacionales e internacionales sobre política antimicrobiana para tratar de unificar criterios aplicables lo más uniforme posible en las instituciones de salud. Material y Método: Se realizó una búsqueda bibliográfica en diferentes bases de datos: Clinical Evidence, The Cochrane Library, PUBMED, Google Académico, MEDLINE, LIS, Scielo, Medscape, LILACS, Latindex, HINARI, MEDIGRAPHIC-NEWS, NIH Reporter y en la web de la OPS/OMS sobre política antimicrobiana, comisión de antibióticos, política de antibióticos. Desarrollo: Se consideraron conceptos de diferentes publicaciones cubanas y consensos internacionales, componentes humanos, objetivos, funciones, recursos, métodos, estrategias y control. Conclusiones: Introducir cualquier modificación terapéutica en la atención médica tiene que ser correctamente valorado en todas sus dimensiones: científica, tecnológica y social. La selección del antibiótico cuando no es posible el estudio microbiológico y/o se carece de antibiograma debe ser hecha sobre las bases clínicas y epidemiológicas locales. La creación de una Política Antimicrobiana con todos sus componentes, recursos y metodología es necesaria más que nunca en estos tiempos. Puede estar sujeta a modificaciones con nuevas evidencias; pero tiene que ser cumplida para disminuir la resistencia microbiana, los costos y obtener mejores resultados(AU)

Introduction: Antimicrobials are one of the most pharmacological groups used in the clinical practice, and its relation to microbial resistance is demonstrated. The rational use of antibiotics can be beneficial from the social and medical point of view, but occasionally, their use is not the most correct one and there should be a systematic and special surveillance. A rational antimicrobial policy is necessary in the health care centers. Objective: To review national and international consensuses and criteria on antimicrobial policy to try to unify criteria and apply them the most uniform way possible in health care centers. Material and method: A bibliographic review on antimicrobial policy, antibiotics commission, and antibiotics policy was made in different databases; some of them were: Clinical Evidence, The Cochrane Library, PUBMED, Academic Google, MEDLINE, LIS, Scielo, Medscape, LILACS, Latindex, HINARI, MEDIGRAPHIC-NEWS, NIH Reporter, and the Web sites of the PAHO/ WHO. Development: Concepts on different Cuban publications, international consensuses, human components, objectives, functions, resources, methods, strategies, and controls were considered. Conclusions: The implementation of any therapeutic modification in the medical attention has to be analyzed correctly in all its dimensions: scientific, technological, and social ones. When the microbiological study is not possible or there is no antibiogram, the selection of the antibiotic should be made on the local epidemiological and clinical basis. The creation of an Antimicrobial Policy with all its components, resources, and methodology is needed now more than ever. It can be submitted to modifications with new evidences, but it has to be fulfilled to reduce both microbial resistance and the costs, and obtain better results(AU)

The Norwegian national project for ethics support in community health and care services.

BACKGROUND: Internationally, clinical ethics support has yet to be implemented systematically in community health and care services. A large-scale Norwegian project (2007-2015) attempted to increase ethical competence in community services through facilitating the implementation of ethics support activities in 241 Norwegian municipalities. The article describes the ethics project and the ethics activities that ensued. METHODS: The article first gives an account of the Norwegian ethics project. Then the results of two online questionnaires are reported, characterizing the scope, activities and organization of the ethics activities in the Norwegian municipalities and the ethical topics addressed. RESULTS: One hundred and thirty-seven municipal contact persons answered the first survey (55 % response rate), whereas 217 ethics facilitators from 48 municipalities responded to the second (33 % response rate). The Norwegian ethics project is vast in scope, yet has focused on some institutions and professions (e.g., nursing homes, home-based care; nurses, nurses' aides, unskilled workers) whilst seldom reaching others (e.g., child and adolescent health care; physicians). Patients and next of kin were very seldom involved. Through the ethics project employees discussed many important ethical challenges, in particular related to patient autonomy, competence to consent, and cooperation with next of kin. The "ethics reflection group" was the most common venue for ethics deliberation. CONCLUSIONS: The Norwegian project is the first of its kind and scope, and other countries may learn from the Norwegian experiences. Professionals have discussed central ethical dilemmas, the handling of which arguably makes a difference for patients/users and service quality. The study indicates that large (national) scale implementation of CES structures for the municipal health and care services is complex, yet feasible.

Institutional Delivery and Satisfaction among Indigenous and Poor Women in Guatemala, Mexico, and Panama.

Indigenous women in Mesoamerica experience disproportionately high maternal mortality rates and are less likely to have institutional deliveries. Identifying correlates of institutional delivery, and satisfaction with institutional deliveries, may help improve facility utilization and health outcomes in this population. We used baseline surveys from the Salud Mesoamérica Initiative to analyze data from 10,895 indigenous and non-indigenous women in Guatemala and Mexico (Chiapas State) and indigenous women in Panama. We created multivariable Poisson regression models for indigenous (Guatemala, Mexico, Panama) and non-indigenous (Guatemala, Mexico) women to identify correlates of institutional delivery and satisfaction. Compared to their non-indigenous peers, indigenous women were substantially less likely to have an institutional delivery (15.2% vs. 41.5% in Guatemala (P<0.001), 29.1% vs. 73.9% in Mexico (P<0.001), and 70.3% among indigenous Panamanian women). Indigenous women who had at least one antenatal care visit were more than 90% more likely to have an institutional delivery (adjusted risk ratio (aRR) = 1.94, 95% confidence interval (CI): 1.44-2.61), compared to those who had no visits. Indigenous women who were advised to give birth in a health facility (aRR = 1.46, 95% CI: 1.18-1.81), primiparous (aRR = 1.44, 95% CI: 1.24-1.68), informed that she should have a Caesarean section (aRR = 1.41, 95% CI: 1.21-1.63), and had a secondary or higher level of education (aRR = 1.36, 95% CI: 1.04-1.79) also had substantially higher likelihoods of institutional delivery. Satisfaction among indigenous women was associated with being able to be accompanied by a community health worker (aRR = 1.15, 95% CI: 1.05-1.26) and facility staff speaking an indigenous language (aRR = 1.10, 95% CI: 1.02-1.19). Additional effort should be exerted to increase utilization of birthing facilities by indigenous and poor women in the region. Improving access to antenatal care and opportunities for higher-level education may increase institutional delivery rates, and providing culturally adapted services may improve satisfaction.