Implementation research on measuring quality in primary care: balancing national needs with learning from the Eastern Mediterranean Region.

BACKGROUND: Universal Health Coverage (UHC) is a core element of ensuring healthy lives, marking the third Sustainable Development Goal. It requires providing quality primary health-care (PHC) services. Assessment of quality of care considering a wide variety of contexts is a challenge. This study lists practical indicators to enhance the quality of PHC. OBJECTIVES: Demonstrating quality indicators for PHC that are feasible, comprehensive and adaptable to wide array of health systems and resource settings. METHODS: We applied the research framework: Exploration, Preparation, Implementation and Sustainment. Exploration included a scoping review to identify quality indicators. Preparation included an eDelphi to refine the primary indicators' list. A panel of 27 experts reviewed the list that was later pilot tested in PHC facilities. The outcomes were presented to two further expert consultations, to refine indicators and plan for broader testing. Implementation included testing the indicators through a five-step process in 40 facilities. A regional consultation in May 2016 discussed the testing outcomes. RESULTS: Initial efforts identified 83 quality indicators at the PHC level that were then refined to a 34-indicator list covering the six domains of quality. A toolkit was also developed to test the feasibility of each indicator measurement, data availability, challenges and gaps. Pilot testing provided insight into modifying and adding some indicators. Wide variability was encountered within and in between facilities, and timely initiation of antenatal care, for example, ranged 31-90% in Oman and 11-98% in Tunisia. Indicators were highly feasible, and 29 out of 34 were measured in 75% of facilities or more. While challenges included gaps in capacity for data collection, the tool showed high adaptability to the local context and was adopted by countries in the Eastern Mediterranean Region (EMR) including Libya, Oman, Iran, Pakistan, Sudan and Palestine. Stakeholders agreed on the high relevance and applicability of the proposed indicators that have been used to inform improvement. CONCLUSION: A cross-regional set of 34 quality indicators of PHC in the EMR was developed and adopted by a diverse group of countries. The toolkit showed high feasibility in pilot testing reflecting the practicality needed to encourage local uptake and sustainability. The core quality indicators are highly adaptable to different local and regional contexts regardless of current PHC strength or available resources. Continuous evaluation and sharing lessons of implementation and use are needed to ascertain the indicators' effectiveness in driving improvements in PHC and to refine and strengthen the evidence supporting the set of indicators for wider adoption.

Quality healthcare in extreme adversity: Developing a framework for action.

Quality issue: Improving quality of care has become a global health priority to improve health outcomes and strengthen health systems, particularly in the context of achieving universal health coverage. Initial assessment: The delivery of quality essential health services in settings of extreme adversity, such as fragile, conflict-affected, vulnerable or disaster contexts, has been identified as a high priority globally to address the massive level of need. Choice of solution: This paper provides an action framework to systematically address the quality of health services for state and non-state actors working in such settings. The framework is designed to be practical, comprehensible and simple in adoption and implementation. It describes challenges, a set of medical needs and population priorities, a menu of quality-related interventions, and a hierarchy of health system levels defining the roles and responsibilities of key actors. Conclusion: Optimizing the use of limited resources in delivering the best quality possible in 'the hardest of the hard settings' is imperative.

Improving quality of care in conflict settings: access and infrastructure are fundamental.

QUALITY PROBLEM OR ISSUE: Armed conflicts pose significant challenges to ensuring timely access to quality health care services for millions around the world. INITIAL ASSESSMENT: Ensuring access and basic infrastructure for conflict-affected populations are overlooked in the global movement to provide quality of care. CHOICE OF SOLUTION: This paper identifies strategies and interventions to improve access to good quality care in settings and communities afflicted by conflict. LESSONS LEARNED: t is crucial to focus more attention on, and develop an evidence base for, ensuring access and basic infrastructure to improve quality of care in conflict-affected regions.

Quality health care in extreme adversity-an action framework.

QUALITY PROBLEM OR ISSUE: There are record-setting numbers of people living in settings of extreme adversity and they continue to increase each year. INITIAL ASSESSMENT: There is a paucity of validated data on quality and safety across settings of extreme adversity. CHOICE OF SOLUTION: This paper argues for an action framework to address the unique challenges of providing quality in extreme adversity. IMPLEMENTATION: We describe a preliminary Quality in Extreme Adversity framework which has been informed by-and will continue to be validated through-literature, data collection, WHO expert consultations and through working in settings of extreme adversity with national authorities and NGOs. LESSONS LEARNED: Poor quality care costs lives, livelihoods and trust in health services. The recommended framework, based on evidence and experiential lessons, intends to address the WHO goal for 2019-2023 of 'one billion people better protected from health emergencies' (9).

Group cell phones are feasible and acceptable for promoting optimal breastfeeding practices in a women's microcredit program in Nigeria.

As part of a breastfeeding promotion intervention trial in Nigeria, we provided one cell phone per group of 5-7 microcredit clients and instructed the group's cell phone recipient to share weekly breastfeeding voice and text messages with group members. We measured the feasibility and acceptability of using group cell phones by conducting semi-structured exit interviews with 195 microcredit clients whose babies were born during the intervention (target group), in-depth interviews with eight phone recipients and nine non-phone recipients, and 16 focus group discussions with other microcredit clients. Women in the target group said the group phone worked well or very well (64%). They were motivated to try the recommended practices because they trusted the information (58%) and had support from others (35%). Approximately 44% of target women reported that their groups met and shared messages at least once a week. Women in groups that met at least weekly had higher odds of exclusive breastfeeding up to 6 months (OR 5.6, 95% CI 1.6, 19.7) than women in groups that never met. In-depth interviews and focus group discussions indicated that non-phone recipients had positive feelings towards phone recipients, the group phone met participants' needs, and messages were often shared outside the group. In conclusion, group cell phone messaging to promote breastfeeding among microcredit clients is feasible and acceptable and can be part of an effective behaviour change package.

Vijana Vijiweni II: a cluster-randomized trial to evaluate the efficacy of a microfinance and peer health leadership intervention for HIV and intimate partner violence prevention among social networks of young men in Dar es Salaam.

BACKGROUND: Intimate partner violence (IPV) and sexually transmitted infections (STIs), including HIV, remain important public health problems with devastating health effects for men and women in sub-Saharan Africa. There have been calls to engage men in prevention efforts, however, we lack effective approaches to reach and engage them. Social network approaches have demonstrated effective and sustained outcomes on changing risk behaviors in the U.S. Our team has identified and engaged naturally occurring social networks comprised mostly of young men in Dar es Salaam in an intervention designed to jointly reduce STI incidence and the perpetration of IPV. These stable networks are locally referred to as "camps." In a pilot study we demonstrated the feasibility and acceptability of a combined microfinance and peer health leadership intervention within these camp-based peer networks. METHODS DESIGN: We are implementing a cluster-randomized trial to evaluate the efficacy of an intervention combining microfinance with health leadership training in 60 camps in Dar es Salaam, Tanzania. Half of the camps have been randomized to the intervention arm, and half to a control arm. The camps in the intervention arm will receive a combined microfinance and health leadership intervention for a period of two years. The camps in the control arm will receive a delayed intervention. We have enrolled 1,258 men across the 60 study camps. Behavioral surveys will be conducted at baseline, 12-months post intervention launch and 30-month post intervention launch and biological samples will be drawn to test for Neisseria gonorrhea (NG), Chlamydia trachomatis (CT), and Trichomonas vaginalis (TV) at baseline and 30-months. The primary endpoints for assessing intervention impact are IPV perpetration and STI incidence. DISCUSSION: This is the first cluster-randomized trial targeting social networks of men in sub-Saharan Africa that jointly addresses HIV and IPV perpetration and has both biological and behavioral endpoints. Effective approaches to engage men in HIV and IPV prevention are needed in low resource, high prevalence settings like Tanzania. If we determine that this approach is effective, we will examine how to adapt and scale up this approach to other urban, sub-Saharan African settings. TRIAL REGISTRATION: Clinical Trials.gov: NCT01865383 . Registration date: May 24, 2013.

Integrating group counseling, cell phone messaging, and participant-generated songs and dramas into a microcredit program increases Nigerian women's adherence to international breastfeeding recommendations.

In northern Nigeria, interventions are urgently needed to narrow the large gap between international breastfeeding recommendations and actual breastfeeding practices. Studies of integrated microcredit and community health interventions documented success in modifying health behaviors but typically had uncontrolled designs. We conducted a cluster-randomized controlled trial in Bauchi State, Nigeria, with the aim of increasing early breastfeeding initiation and exclusive breastfeeding among female microcredit clients. The intervention had 3 components. Trained credit officers led monthly breastfeeding learning sessions during regularly scheduled microcredit meetings for 10 mo. Text and voice messages were sent out weekly to a cell phone provided to small groups of microcredit clients (5-7 women). The small groups prepared songs or dramas about the messages and presented them at the monthly microcredit meetings. The control arm continued with the regular microcredit program. Randomization occurred at the level of the monthly meeting groups. Pregnant clients were recruited at baseline and interviewed again when their infants were aged ≥6 mo. Logistic regression models accounting for clustering were used to estimate the odds of performing recommended behaviors. Among the clients who completed the final survey (n = 390), the odds of exclusive breastfeeding to 6 mo (OR: 2.4; 95% CI: 1.4, 4.0) and timely breastfeeding initiation (OR: 2.6; 95% CI: 1.6, 4.1) were increased in the intervention vs. control arm. Delayed introduction of water explained most of the increase in exclusive breastfeeding among clients receiving the intervention. In conclusion, a breastfeeding promotion intervention integrated into microcredit increased the likelihood that women adopted recommended breastfeeding practices. This intervention could be scaled up in Nigeria, where local organizations provide microcredit to >500,000 clients. Furthermore, the intervention could be adopted more widely given that >150 million women, many of childbearing age, are involved in microfinance globally.

Afghanistan's national strategy for improving quality in health care.

QUALITY PROBLEM OR ISSUE: When the Ministry of Public Health (MoPH) of the Islamic Republic of Afghanistan began reconstructing the health system in 2003, it faced serious challenges. Decades of war had severely damaged the health infrastructure and the country's ability to deliver health services. INITIAL ASSESSMENT: A national health resources assessment in 2002 revealed huge structural and resource disparities fundamental to improving health care. For example, only 9% of the population was able to access basic health services, and about 40% of health facilities had no female health providers, severely constraining access of women to health care. Multiple donor programs and the MoPH had some success in improving quality, but questions about sustainability, as well as fragmentation and poor coordination, existed. PLAN OF ACTION: In 2009, MoPH resolved to align and accelerate quality improvement efforts as well as build structural and skill capacity. IMPLEMENTATION: The MoPH established a new quality unit within the ministry and undertook a year-long consultative process that drew on international evidence and inputs from all levels of the health system to developed a National Strategy for Improving Quality in Health Care consisting of a strategy implementation framework and a five-year operational plan. LESSONS LEARNED: Even in resource-restrained countries, under the most adverse circumstances, quality of health care can be improved at the front-lines and a consensual and coherent national quality strategy developed and implemented.

Strengthening the quality agenda in health care in low- and middle-income countries: questions to consider.

There is a widespread interest in strengthening the quality agenda in low- and middle-income countries, but the optimal strategies for achieving this are not well defined. We offer an appraisal of the health challenges these countries are confronting, the resources and services provided by their health systems and the spectrum of options between policy and practice. Global health context section presents a brief discussion of the global health context. A descriptive picture of health and health care in LMIC section discusses the specific health conditions and the health-care environment in developing nations, using traditional health and health services indicators as reference points. Questions to consider for strengthening the quality improvement agenda in low and middle-income countries section sets forth key questions that quality improvement professionals should consider in the design of a quality agenda for low- and middle-income countries.

Charting the way forward to better quality health care: how do we get there and what are the next steps? Recommendations from the Salzburg Global Seminar on making health care better in low- and middle-income economies.

OBJECTIVE: In April 2012, the Salzburg Global Seminar (SGS) brought together 58 health leaders from 33 countries to review experiences in improving the quality and safety of health-care services in low- and middle-income countries, synthesize lessons learned from those experiences, discuss challenges and opportunities and recommend next steps to stimulate improvement in such countries. This work summarizes the seminar's key results, expressed as five shared challenges and five lessons learned. DESIGN: The seminar featured a series of interactive sessions with an all-teach, all-learn approach. Session topics were: introduction to the seminar, journey to date, challenges that lie ahead, overcoming the issues of confusion, sustaining execution, strengthening leadership and policy, the role of quality improvement in health systems strengthening and setting the agenda for learning and next steps. RESULTS: Key lessons from the SGS include reducing terminology and methodology confusion, strengthening the learning agenda, embracing improvement science as a means for strengthening health-care systems, developing leadership in improving health care and ensuring that health-care systems focus on patients and communities. A call to action was developed by SGS participants and presented at the 65th World Health Assembly in Geneva. CONCLUSION: There is an inarguable need to move improvement in health care to a new level to attain and exceed the Millennium Development Goals. The challenges can be overcome through concerted action of key stakeholders and the application of scientifically grounded management methods to enable the reliable implementation of high-impact interventions for every patient every time needed.

Chartbook: shining a light on the quality of healthcare in Canada: what can be learned to catalyze improvements in healthcare quality?

This paper provides a reflection on the findings of Canada's first-ever chartbook on the quality of healthcare in Canada. Quality of Healthcare in Canada: A Chartbook was published in 2010 by the Canadian Health Services Research Foundation in partnership with the Canadian Institute for Health Information and the Canadian Patient Safety Institute, and with support from Statistics Canada. This paper, by the chartbook authors (Sutherland and Leatherman) and colleagues (Law, Verma and Petersen), presents selected key findings and lessons from the chartbook and aims to serve as a catalyst for ideas and discussion in the papers that follow. The chartbook identified a lack of common language and indicators on quality across Canada's provinces and territories, underscoring the need to create and coordinate core measures. The Canadian chartbook and this issue of Healthcare Papers provide an update on the existing quality measures and the state of healthcare quality in Canada, and create the opportunity for jurisdictions to learn from one another and to contemplate the steps required to improve quality across the country.

Safety in fragile, conflict-affected, and vulnerable settings: An evidence scanning approach for identifying patient safety interventions.

Background: The number of people living in fragile, conflict-affected, and vulnerable (FCV) settings is growing rapidly and attention to achieving universal health coverage must be accompanied by sufficient focus on the safety of care for universal access to be meaningful. Healthcare workers in these settings are working under extreme conditions, often with insufficient contextualized evidence to support decision-making. Recognising the relative paucity of, and methodological issues in gathering evidence from these settings, the evidence scanning described in this paper considered which patient safety interventions might offer the 'better bet', eg, the most effective and appropriate intervention in FCV settings. Methods: An evidence scanning approach was used to examine the literature. The search was limited to FCV settings and low-income settings as defined by the World Bank, but if a systematic review included a mix of evidence from FCV/low income settings, as well as low-middle income settings, it was included. The search was conducted in English and limited to studies published from 2003 onwards, utilising Google Scholar as a publicly accessible database and further review of the grey literature, with specific attention to the outputs of non-governmental organisations. The search and subsequent analysis were completed between April and June 2020. Results: The majority of studies identified related to strengthening infection prevention and control which was also found to be the 'better bet' intervention that could generalise to other settings, be most feasible to implement, and most effective for improving patient care and associated outcomes. Other prioritized interventions include risk management, with contributing elements such as reporting, audits, and death review processes. Conclusions: Infection prevention and control interventions dominate in the literature for multiple reasons including strength of evidence, acceptability, feasibility, and impact on patient and health worker well-being. However, there is an urgent need to further develop the evidence base, specialist knowledge, and field guidance on a range of other patient safety interventions such as education and training, patient identification, subject specific safety actions, and risk management.

Quality of health care and patient safety in extreme adversity settings in the Eastern Mediterranean Region: a qualitative multicountry assessment.

BACKGROUND: Quality and patient safety are essential for the provision of effective health care services. Research on these aspects is lacking in settings of extreme adversity. AIMS: This study aimed to explore the perception of health care stakeholders working in extreme adversity settings of the quality of health care and patient safety. METHODS: This was a qualitative study conducted through semistructured interviews with 26 health care stakeholders from seven countries of the World Health Organization's Eastern Mediterranean Region which are experiencing emergencies. The interviews explored the respondents' perspectives of four aspects of quality and patient safety: definition of the quality of health care, challenges to the provision of good quality health care in emergency settings, priority health services and populations in emergency settings, and interventions to improve health care quality and patient safety. RESULTS: The participants emphasized that saving lives was the main priority in extreme adversity settings. While all people living in emergency situations were vulnerable and at risk, the respondents considered women and children, poor and disabled people, and those living in hard-to-reach areas the priority populations to be targeted by improvement interventions. The challenges to quality of health care were: financing problems, service inaccessibility, insecurity of health workers, break down in health systems, and inadequate infrastructure. Respondents proposed interventions to improve quality, however, their effective implementation remains challenging in these exceptional settings. CONCLUSIONS: The interventions identified can serve as a basis for improvements in health care quality that could be adapted to extreme adversity settings.

How to improve patient safety in fragile, conflict-affected and vulnerable settings: a Delphi study protocol.

INTRODUCTION: There is a high burden of adverse events and poor outcomes in fragile, conflict-affected and vulnerable (FCV) settings. To improve outcomes, there is a need to better identify which interventions can improve patient safety in these settings, as well as to develop strategies to optimise their implementation. OBJECTIVE: This study intends to generate a consensus on the most relevant patient safety interventions from experts with experience on FCV settings, including frontline clinicians and managers/administrators, non-governmental organisations, policymakers and researchers. METHODS AND ANALYSIS: The study uses an online Delphi research approach (eDelphi). Participants will include experts from a range of backgrounds, including those working in a variety of FCV settings. Participants will be established contacts known to the research team or recruited via snowball sampling, and will be asked to identify and rank the importance of a variety of patient safety interventions. Consensus will be defined as >70% of participants agreeing/strongly agreeing or disagreeing/strongly disagreeing with a statement. Data analysis will be completed in Microsoft Excel and NVivo. The primary outcome of the study will be a list of the most relevant and applicable patient safety interventions for FCV settings. ETHICS AND DISSEMINATION: The study has received approval from Imperial College London Ethics Committee (reference number 20IC665). Anonymous results will be made available to the public, academic organisations and policymakers.