From Kisiizi to Baltimore: cultivating knowledge brokers to support global innovation for community engagement in healthcare.

BACKGROUND: Reverse Innovation has been endorsed as a vehicle for promoting bidirectional learning and information flow between low- and middle-income countries and high-income countries, with the aim of tackling common unmet needs. One such need, which traverses international boundaries, is the development of strategies to initiate and sustain community engagement in health care delivery systems. OBJECTIVE: In this commentary, we discuss the Baltimore "Community-based Organizations Neighborhood Network: Enhancing Capacity Together" Study. This randomized controlled trial evaluated whether or not a community engagement strategy, developed to address patient safety in low- and middle-income countries throughout sub-Saharan Africa, could be successfully applied to create and implement strategies that would link community-based organizations to a local health care system in Baltimore, a city in the United States. Specifically, we explore the trial's activation of community knowledge brokers as the conduit through which community engagement, and innovation production, was achieved. Cultivating community knowledge brokers holds promise as a vehicle for advancing global innovation in the context of health care delivery systems. As such, further efforts to discern the ways in which they may promote the development and dissemination of innovations in health care systems is warranted. TRIAL REGISTRATION: Trial Registration Number: NCT02222909 . Trial Register Name: Reverse Innovation and Patient Engagement to Improve Quality of Care and Patient Outcomes (CONNECT). Date of Trial's Registration: August 22, 2014.

The role of South-North partnerships in promoting shared learning and knowledge transfer.

While it is clear that hospitals in developing countries need to improve quality of health services and improve patient safety, hospitals in high resource countries need to do the same. Most often the focus on improvement through institutional health partnerships involves hospital teams from high resource settings attempting to aid and teach hospital staff in low resource settings, particularly in Africa. However these efforts to provide assistance may be more satisfying and sustainable if we understand that partnership learning is bi-directional whereby hospital teams from high resource settings also benefit. One particular partnership-based model that demonstrates this benefit to high resource partners is the World Health Organization African Partnerships for Patient Safety (APPS). Johns Hopkins Medicine Armstrong Institute for Patient Safety & Quality (AI) through the APPS model has co-created twinning partnerships with hospitals in Uganda, South Sudan & Liberia. This commentary aims to deconstruct specific learnings that have benefited the Johns Hopkins AI community through the APPS partnership.

Strengthening the evidence-policy interface for patient safety: enhancing global health through hospital partnerships.

Strengthening the evidence-policy interface is a well-recognized health system challenge in both the developed and developing world. Brokerage inherent in hospital-to-hospital partnerships can boost relationships between "evidence" and "policy" communities and move developing countries towards evidence based patient safety policy. In particular, we use the experience of a global hospital partnership programme focused on patient safety in the African Region to explore how hospital partnerships can be instrumental in advancing responsive decision-making, and the translation of patient safety evidence into health policy and planning. A co-developed approach to evidence-policy strengthening with seven components is described, with reflections from early implementation. This rapidly expanding field of enquiry is ripe for shared learning across continents, in keeping with the principles and spirit of health systems development in a globalized world.

Developed-developing country partnerships: benefits to developed countries?

Developing countries can generate effective solutions for today's global health challenges. This paper reviews relevant literature to construct the case for international cooperation, and in particular, developed-developing country partnerships. Standard database and web-based searches were conducted for publications in English between 1990 and 2010. Studies containing full or partial data relating to international cooperation between developed and developing countries were retained for further analysis. Of 227 articles retained through initial screening, 65 were included in the final analysis. The results were two-fold: some articles pointed to intangible benefits accrued by developed country partners, but the majority of information pointed to developing country innovations that can potentially inform health systems in developed countries. This information spanned all six WHO health system components. Ten key health areas where developed countries have the most to learn from the developing world were identified and include, rural health service delivery; skills substitution; decentralisation of management; creative problem-solving; education in communicable disease control; innovation in mobile phone use; low technology simulation training; local product manufacture; health financing; and social entrepreneurship. While there are no guarantees that innovations from developing country experiences can effectively transfer to developed countries, combined developed-developing country learning processes can potentially generate effective solutions for global health systems. However, the global pool of knowledge in this area is virgin and further work needs to be undertaken to advance understanding of health innovation diffusion. Even more urgently, a standardized method for reporting partnership benefits is needed--this is perhaps the single most immediate need in planning for, and realizing, the full potential of international cooperation between developed and developing countries.

Health-care-associated infection in Africa: a systematic review.

OBJECTIVE: To assess the epidemiology of endemic health-care-associated infection (HAI) in Africa. METHODS: Three databases (PubMed, the Cochrane Library, and the WHO regional medical database for Africa) were searched to identify studies published from 1995 to 2009 on the epidemiology of HAI in African countries. No language restriction was applied. Available abstract books of leading international infection control conferences were also searched from 2004 to 2009. FINDINGS: The eligibility criteria for inclusion in the review were met by 19 articles, only 2 of which met the criterion of high quality. Four relevant abstracts were retrieved from the international conference literature. The hospital-wide prevalence of HAI varied between 2.5% and 14.8%; in surgical wards, the cumulative incidence ranged from 5.7% to 45.8%. The largest number of studies focused on surgical site infection, whose cumulative incidence ranged from 2.5% to 30.9%. Data on causative pathogens were available from a few studies only and highlighted the importance of gram-negative rods, particularly in surgical site infection and ventilator-associated pneumonia. CONCLUSION: Limited information is available on the endemic burden of HAI in Africa, but our review reveals that its frequency is much higher than in developed countries. There is an urgent need to identify and implement feasible and sustainable approaches to strengthen HAI prevention, surveillance and control in Africa.

Folic acid supplementation for the prevention of neural tube defects: an update of the evidence for the U.S. Preventive Services Task Force.

BACKGROUND: Neural tube defects (NTDs) are among the most common birth defects in the United States. In 1996, the U.S. Preventive Services Task Force (USPSTF) recommended that all women planning a pregnancy or capable of conception take a supplement containing folic acid to reduce the risk for NTDs. PURPOSE: To search for new evidence published since 1996 on the benefits and harms of folic acid supplementation for women of childbearing age to prevent neural tube defects in offspring, to inform an updated USPSTF recommendation. DATA SOURCES: MEDLINE and Cochrane Central Register of Controlled Trials searches from January 1995 through December 2008, recent systematic reviews, reference lists of retrieved articles, and expert suggestions. STUDY SELECTION: English-language randomized, controlled trials; cohort studies; case-control studies; systematic reviews; and meta-analyses were selected if they provided information on the benefits and harms of folic acid supplementation in women of childbearing age to reduce NTDs in offspring. DATA EXTRACTION: All studies were reviewed, abstracted, and rated for quality by using predefined USPSTF criteria. DATA SYNTHESIS: Four observational studies reported benefit of reduction of risk for NTDs associated with folic acid-containing supplements. Differences in study type and methods prevent the calculation of a summary of the reduction in risk. The one included study on harms reported that the association of twinning with folic acid intake disappeared after adjustment for in vitro fertilization and underreporting of folic acid intake. LIMITATIONS: The evidence on dose was limited. No evidence was found on the potential harm of masking vitamin B(12) deficiency in women of childbearing age. The search focused on the association of NTDs with supplementation only and therefore does not provide a comprehensive review of the effects of folic acid on all possible outcomes or of the effects of dietary intake of folic acid. CONCLUSION: New observational evidence supports previous evidence from a randomized, controlled trial that folic acid-containing supplements reduce the risk for NTD-affected pregnancies. The association of folic acid use with twin gestation may be confounded by fertility interventions.

African partnerships for patient safety: a vehicle for enhancing patient safety across two continents. [corrected].

African Partnerships for Patient Safety (APPS) aims to develop sustainable partnerships between hospitals in Africa and Europe to create a network of beacon hospitals for patient safety. The three core APPS objectives are focused on building strong patient safety partnerships between hospitals in Africa and Europe, implementing patient safety improvements in each partnership hospital on 12 patient safety action areas, and facilitating spread of patient safety improvements. APPS is working with six first wave hospital partnerships and will capture and report learning from implementation. A range of APPS resources will shortly be available to hospitals working on patient safety systems.

Pertussis-associated hospitalizations in American Indian and Alaska Native infants.

OBJECTIVE: To investigate the burden of pertussis in American Indian and Alaska Native (AI/AN) infants. STUDY DESIGN: AI/AN pertussis-associated hospitalizations between 1980 and 2004 were evaluated using Indian Health Service (IHS)/tribal inpatient data, which include all reported hospitalizations within the IHS/tribal health care system. RESULTS: Between 1980 and 2004, 483 pertussis-associated hospitalizations in AI/AN infants were documented; 88% of cases involved infants age < 6 months. For this entire period, the average annual hospitalization rate was 132.7 per 100,000 AI/AN infants (95% confidence interval [CI] = 121.3 to 145.2), and 234.5 per 100,000 AI/AN infants age < 6 months (95% CI = 213.1 to 258.1). Between 2000 and 2004, the annual hospitalization rate was 100.5 per 100,000 AI/AN infants (95% CI = 81.6 to 123.7), which exceeds the estimated 2003 pertussis hospitalization rate of 67.7 per 100,000 in the general US infant population (95% CI = 61.9 to 73.5). The highest pertussis hospitalization rates in 2000 to 2004 were in AI/AN infants in the Alaska and Southwestern IHS regions of the United States. CONCLUSIONS: The burden of pertussis in AI/AN infants is high, particularly so in infants age < 6 months in the Alaska and the Southwestern IHS regions of the United States. Ensuring implementation of vaccination strategies to reduce the incidence of pertussis in AI/AN, infants, adolescents, and adults alike is warranted to reduce the burden of pertussis in AI/AN infants.

Exploring evidence-policy linkages in health research plans: a case study from six countries.

The complex evidence-policy interface in low and middle income country settings is receiving increasing attention. Future Health Systems (FHS): Innovations for Equity, is a research consortium conducting health systems explorations in six Asian and African countries: Bangladesh, India, China, Afghanistan, Uganda, and Nigeria. The cross-country research consortium provides a unique opportunity to explore the research-policy interface. Three key activities were undertaken during the initial phase of this five-year project. First, key considerations in strengthening evidence-policy linkages in health system research were developed by FHS researchers through workshops and electronic communications. Four key considerations in strengthening evidence-policy linkages are postulated: development context; research characteristics; decision-making processes; and stakeholder engagement. Second, these four considerations were applied to research proposals in each of the six countries to highlight features in the research plans that potentially strengthen the research-policy interface and opportunities for improvement. Finally, the utility of the approach for setting research priorities in health policy and systems research was reflected upon. These three activities yielded interesting findings. First, developmental consideration with four dimensions - poverty, vulnerabilities, capabilities, and health shocks - provides an entry point in examining research-policy interfaces in the six settings. Second, research plans focused upon on the ground realities in specific countries strengthens the interface. Third, focusing on research prioritized by decision-makers, within a politicized health arena, enhances chances of research influencing action. Lastly, early and continued engagement of multiple stakeholders, from local to national levels, is conducive to enhanced communication at the interface. The approach described has four main utilities: first, systematic analyses of research proposals using key considerations ensure such issues are incorporated into research proposals; second, the exact meaning, significance, and inter-relatedness of these considerations can be explored within the research itself; third, cross-country learning can be enhanced; and finally, translation of evidence into action may be facilitated. Health systems research proposals in low and middle income countries should include reflection on transferring research findings into policy. Such deliberations may be informed by employing the four key considerations suggested in this paper in analyzing research proposals.

Exploring health systems research and its influence on policy processes in low income countries.

BACKGROUND: The interface between research and policymaking in low-income countries is highly complex. The ability of health systems research to influence policy processes in such settings face numerous challenges. Successful analysis of the research-policy interface in these settings requires understanding of contextual factors as well as key influences on the interface. Future Health Systems (FHS): Innovations for Equity is a consortium conducting research in six countries in Asia and Africa. One of the three cross-country research themes of the consortium is analysis of the relationship between research (evidence) and policy making, especially their impact on the poor; insights gained in the initial conceptual phase of FHS activities can inform the global knowledge pool on this subject. DISCUSSION: This paper provides a review of the research-policy interface in low-income countries and proposes a conceptual framework, followed by directions for empirical approaches. First, four developmental perspectives are considered: social institutional factors; virtual versus grassroots realities; science-society relationships; and construction of social arrangements. Building on these developmental perspectives three research-policy interface entry points are identified: 1. Recognizing policy as complex processes; 2. Engaging key stakeholders: decision-makers, providers, scientists, and communities; and 3. Enhancing accountability. A conceptual framework with three entry points to the research-policy interface - policy processes; stakeholder interests, values, and power; and accountability - within a context provided by four developmental perspectives is proposed. Potential empirical approaches to the research-policy interface are then reviewed. Finally, the value of such innovative empirical analysis is considered. CONCLUSION: The purpose of this paper is to provide the background, conceptual framework, and key research directions for empirical activities focused on the research-policy interface in low income settings. The interface can be strengthened through such analysis leading to potential improvements in population health in low-income settings. Health system development cognizant of the myriad factors at the research-policy interface can form the basis for innovative future health systems.

Development of an evaluation framework for African-European hospital patient safety partnerships.

BACKGROUND: Patient safety is recognised as a significant healthcare problem worldwide, and healthcare-associated infections are an important aspect. African Partnerships for Patient Safety is a WHO programme that pairs hospitals in Africa with hospitals in Europe with the objective to work together to improve patient safety. OBJECTIVE: To describe the development of an evaluation framework for hospital-to-hospital partnerships participating in the programme. METHODS: The framework was structured around the programme's three core objectives: facilitate strong interhospital partnerships, improve in-hospital patient safety and spread best practices nationally. Africa-based clinicians, their European partners and experts in patient safety were closely involved in developing the evaluation framework in an iterative process. RESULTS: The process defined six domains of partnership strength, each with measurable subdomains. We developed a questionnaire to measure these subdomains. Participants selected six indicators of hospital patient safety improvement from a short-list of 22 based on their relevance, sensitivity to intervention and measurement feasibility. Participants proposed 20 measures of spread, which were refined into a two-part conceptual framework, and a data capture tool created. CONCLUSION: Taking a highly participatory approach that closely involved its end users, we developed an evaluation framework and tools to measure partnership strength, patient safety improvements and the spread of best practice.

Knowledge brokering for evidence-based urban health policy: a proposed framework.

This paper presents a multidimensional approach to examining the urban evidence-policy interface in low- and middle-income countries (LMICs), and applies this approach to a case study from Pakistan. Key features of urban health policy and the significance of the evidence-policy interface in rapidly changing LMICs are articulated; characteristics of evidence that has been successfully incorporated into health policy are also defined. An urban health evidence-to-policy exploratory framework for LMICs based on innovative multidisciplinary thinking and pivotal knowledge brokering is presented. Application of the framework to a case study on road transport and health in urban Pakistan underscores the opportunities and utility of knowledge brokering. Public health practitioners can become knowledge brokers at the evidence-policy interface to develop a concerted, coordinated and informed response to urban health challenges in LMICs.