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1.
Artigo em Inglês | MEDLINE | ID: mdl-32188037

RESUMO

High-quality intrapartum care, including intermittent monitoring of fetal heart rates (FHR) to detect and manage abnormalities, is recommended by WHO and the Government of Tanzania (GoT) and creates potential to save newborn lives in Tanzania. Handheld Doppler devices have been investigated in several low-resource countries as an alternative to Pinard stethoscope and are more sensitive to detecting accelerations and decelerations of the fetal heart as compared to Pinard. This study assessed perspectives of high-level Tanzanian policymakers on facilitators and barriers to scaling up use of the hand-held Doppler for assessing FHR during labor and delivery. From November 2018-August 2019, nine high-level policymakers and subject matter experts were interviewed using a semi-structured questionnaire, with theoretical domains drawn from Proctor's implementation outcomes framework. Interviewees largely saw use of Doppler to improve intrapartum FHR monitoring as aligning with national priorities, though they noted competing demands for resources. They felt that GoT should fund Doppler, but prioritization and budgeting should be driven from district level. Recommended ways forward included learning from scale up of Helping Babies Breathe rollout, making training approaches effective, using clinical mentoring, and establishing systematic monitoring of outcomes. To be most effective, introduction of Doppler must be concurrent with improving case management practices for abnormal intrapartum FHR. WHO's guidance on scale-up, as well as implementation science frameworks, should be considered to guide implementation and evaluation.

2.
BMJ Open ; 9(12): e034302, 2019 Dec 11.
Artigo em Inglês | MEDLINE | ID: mdl-31831551

RESUMO

INTRODUCTION: Both US and global communities lag on key health indicators. There has been limited progress in building capacity to improve health beyond the healthcare field. Yet, communities also need to engage in health improvement initiatives. A substantial body of literature describes standards and core components for quality improvement (QI) approaches in clinical settings. This study aims to determine how communities in the USA, Australia, New Zealand and Canada use QI approaches for health and well-being improvement and how such approaches compare to those in clinical settings. METHODS AND ANALYSIS: We developed a study protocol based on scoping review framework by Arksey and O'Malley, methodological advancements for scoping studies (Levac et al ) and other published protocols. We developed research questions in an iterative process and used the Population, Intervention, Comparison, Outcomes strategy to determine eligibility criteria. Electronic databases deemed appropriate (Web of Science, Scopus, and Proquest Health Management) will be searched for studies that meet inclusion criteria. References of included studies will be included when relevant. Two reviewers will independently screen all abstracts and full-text studies for inclusion. A third reviewer will adjudicate disagreements that arise. An instrument will be developed to extract data from included studies. Quantitative and qualitative results will be reported. ETHICS AND DISSEMINATION: We developed this protocol to systematically conduct a scoping review of how US communities use QI approaches to address community health and well-being. Results will benefit multiple stakeholders by informing how to better support, design and evaluate community well-being improvement interventions. Results will be distributed through peer-reviewed journals, conferences, presentations and a public health graduate course.

3.
BMJ Open Qual ; 8(3): e000540, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31523733

RESUMO

Quality improvement (QI) approaches have demonstrated a lot of promise in improving clinical care processes, both in high-resource and low-resource settings. However, most examples of QI initiatives in healthcare in low-income countries are clinic-based. The objective of this study was to demonstrate feasibility of applying QI methods in low-resource community settings by applying them to the problem of correct utilisation of long-lasting insecticidal nets (LLINs) in a rural community in Burundi. Correct utilisation of LLINs had been shown to be a cost-effective approach to malaria prevention. In Burundi, LLINs utilisation is low. The Model for Improvement, a well-known QI approach, was used to increase LLINs utilisation in a rural community in Burundi. In the baseline, LLINs ownership and weekly utilisation together with factors affecting LLINs non-use were documented for a period of 4 weeks before intervention. Improvement ideas were collaboratively developed by a quality improvement team (QIT) and tested using Plan-Do-Study-Act (PDSA) cycles. The first PDSA cycle consisted of the demonstration of how to mount LLINs, the second was an implementation of reminders done by household 'watchdogs', the third cycle consisted of conducting two community reminders every week and the last cycle was a combination of the last two PDSA cycles. The intervention lasted 4 weeks and data were collected weekly. LLINs utilisation was calculated each week and plotted on a run chart to demonstrate improvement trends. LLINs utilisation data were collected for another 3 weeks postintervention. Of 96 households, 83 (87%) households owned at least one LLIN. After intervention, the number of LLINs used increased from 32% to 75% (134% increase) and the number of persons (general population) sleeping under LLINs from 35% to 73% (108% increase). The number of children under 5 years sleeping under LLINs increased from 31% to 76% (145% increase) and the number of pregnant women who slept under LLINs from 43% to 73% (69% increase). Also, the averages of the number of nights in each week that the general population slept under LLINs increased from 2.13 to 5.11 (140% increase), children under 5 years from 1.68 to 4.78 (184% increase) and pregnant women from 1.56 to 4.47 (186% increase). Each of the 4 PDSA cycles led to a significant increase in outcome indicators and the trends appear to persist even after the implementation was complete. While it is impossible to draw generalisable conclusions from a small pilot study, QI approaches appear to be feasible to implement in low-resource community setting and have promise in producing results. More research at larger scale should be encouraged to validate our initial findings.

4.
BMC Health Serv Res ; 19(1): 491, 2019 Jul 15.
Artigo em Inglês | MEDLINE | ID: mdl-31307446

RESUMO

BACKGROUND: Resistance to antimalarial drugs resulting from overuse of the medication remains a threat to malaria control and elimination in endemic settings including Ghana. Reliance on clinical signs alone results in patients being diagnosed with malaria falsely. The World Health Organization and local guidelines recommend test-based diagnosis with malaria rapid diagnostic test (mRDT) or microscopy before prescription of antimalarial drugs. Despite the scale-up of mRDT through the procurement of mRDT kits and training of health workers on mRDT-led diagnosis of malaria, its use remains low with about 85% health workers reporting satisfaction with the presumptive diagnosis. METHODS: A quantitative cross-sectional study was conducted to investigate the determinants of intention to use mRDT among health workers in Kintampo North Municipality, Ghana. A total of 110 health workers were surveyed from February to April 2017. Intention to use mRDT was measured as the primary outcome with a 5-item scale questionnaire based on the Technology Acceptance Model (TAM). We then tested its association with hypothesized determinants: coherence, cognitive participation, collective action, and reflexive action informed by the Normalization Process Theory (NPT) as well as health workers' background characteristics using linear regression modeling. RESULTS: The mean intention to use mRDT score was 82% (SD: 12.6). The regression model showed health workers intention to use mRDT was positively associated with coherence (ß = 0.40, 95% CI 0.16-0.65) and cognitive participation (ß = 0.36, 95% CI 0.15-0.58). Intention to use mRDT score was 6.85 units higher among health workers with three or more years of experience compared to those with less than 3 years of experience (ß = 6.85 95% CI 0.59-13.12). However, intention to use mRDT score was inversely related to reflexive monitoring and collective action but not significant. CONCLUSION: The study identified that intention to use mRDT was positively influenced by health workers having a proper understanding of the aims and expected benefits (coherence) of the intervention and the availability of experienced staff and intervention champions (cognitive participation) to promote mRDT use among health workers.


Assuntos
Testes Diagnósticos de Rotina/métodos , Pessoal de Saúde/psicologia , Intenção , Malária/diagnóstico , Kit de Reagentes para Diagnóstico , Adulto , Antimaláricos , Estudos Transversais , Feminino , Gana , Humanos , Masculino , Inquéritos e Questionários , Adulto Jovem
6.
Health Educ Behav ; 46(1_suppl): 100S-109S, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-30982339

RESUMO

Spreading Community Accelerators Through Learning and Evaluation (SCALE) was a Robert Wood Johnson Foundation-funded initiative from 2015 to 2017 to build capability of 24 community coalitions to advance health, well-being, and equity. The SCALE theory of change had three components: develop leadership capability, build relationships within and between communities, and create an intercommunity system to spread promising ideas. The theory was operationalized through training academies, coaching, and peer-to-peer learning that explicitly addressed equity and systems change. In this article, we describe how SCALE facilitated community transformation related to Collaborating for Equity and Justice Principles 1, 3, 4, and 6. We conducted a multiple-case study approach with two community coalitions including site visits, interviews, and observation to illuminate underlying mechanisms of change by exploring how and why change occurs. Skid Row Women worked with women experiencing homelessness in Los Angeles to address diabetes and food systems. Healthy Livable Communities of Cattaraugus County used a portfolio of projects in order to create system changes to improve population health and increase access to services for people with disabilities in rural New York State. Through our analysis, we describe how two coalitions used SCALE tools for collaborative coalition processes such as aim setting, relationship building, and shared decision making with community residents. Our findings suggest that advancing Collaborating for Equity and Justice principles requires self-reflection and courage; new ways of being in relationship; learning from failure; productive conflict to explicitly address power, racism, and other forms of oppression; and methods to test systems improvement ideas.

7.
BMJ Open ; 9(3): e026016, 2019 03 30.
Artigo em Inglês | MEDLINE | ID: mdl-30928948

RESUMO

OBJECTIVES: This study evaluates the real-world effectiveness of Diagnose-Intervene-Verify-Adjust (DIVA), an innovative quality improvement mode, in improving primary healthcare (PHC) bottlenecks impeding health system performance in Kaduna, a northern Nigerian state. DESIGN: An embedded mixed method study design involving participant observation. SETTING: PHCs in 23 local government areas of Kaduna state, Nigeria. PARTICIPANTS: 138 PHC managers across the state (PHC directors and programme managers in the 23 local governments). INTERVENTION: DIVA is a four-step improvement model in which 'Diagnose' identifies constraints to effective coverage, 'Intervene' develops/implements action plans addressing constraints, while 'Verify/Adjust' monitor performance and revise plans. PRIMARY AND SECONDARY OUTCOME MEASURES: The model, as adapted in Nigeria, is designed to evaluate and improve the availability of health commodities, human resources, geographical accessibility, acceptability, continuous utilisation and quality of four PHC interventions (immunisation, integrated management of childhood illnesses, antenatal care and skilled birth attendance). RESULTS: 183 bottlenecks were identified by local government teams across all interventions in 2013. 41% of bottlenecks concern human resources. Geographical access and availability of commodities ranked least. Availability of commodities was the most improved determinant although among the least constrained, probably indicating skewed implementation of operational plans. 1562 activities were planned to address identified bottlenecks in the state, of which only 568 (36%) were completely implemented CONCLUSION: Our study demonstrates that PHC planning using the DIVA model can potentially improve health system performance. However, effective implementation is critical and may require some central government oversight.

8.
Implement Sci ; 14(1): 18, 2019 02 28.
Artigo em Inglês | MEDLINE | ID: mdl-30819223

RESUMO

BACKGROUND: Many public health programs fail because of an inability to implement tested interventions in diverse, complex settings. The field of implementation science is engaged in developing strategies for successful implementation, but current training is primarily researcher-focused. To tackle the challenges of the twenty-first century, public health leaders are promoting a new model titled Public Health 3.0 where public health practitioners become "chief health strategists" and develop interdisciplinary skills for multisector engagement to achieve impact. This requires broad training for public health practitioners in implementation science that includes the allied fields of systems and design thinking, quality improvement, and innovative evaluation methods. At UNC Chapel Hill's Gillings School of Global Public Health, we created an interdisciplinary set of courses in applied implementation science for Master of Public Health (MPH) students and public health practitioners. We describe our rationale, conceptual approach, pedagogy, courses, and initial results to assist other schools contemplating similar programs. METHODS: Our conceptual approach recognized the vital relationship between implementation research and practice. We conducted a literature review of thought leaders in public health to identify skill areas related to implementation science that are priorities for the future workforce. We also reviewed currently available training programs in implementation science to understand their scope and objectives and to assess whether any of these would be a fit for these priorities. We used a design focused implementation framework to create four linked courses drawing from multiple fields such as engineering, management, and the social sciences and emphasizing application through case studies. We validated the course content by mapping them to implementation science competencies in the literature. RESULTS: To date, there is no other program that provides comprehensive interdisciplinary skills in applied implementation science for MPH students. As of April 2018, we have offered a total of eleven sections of the four courses, with a total enrollment of 142, of whom 127 have been master's-level students in the school of public health. Using Kirkpatrick's Model, we found positive student reaction, learning, and behavior. Many students have completed applied implementation science focused practicums, master's papers, and special studies. CONCLUSIONS: A systematically designed interdisciplinary curriculum in applied implementation science for MPH students has been found by students to be a useful set of skills. Students have demonstrated the capability to master this material and incorporate it into their practicums and master's papers.


Assuntos
Fortalecimento Institucional , Educação de Pós-Graduação/métodos , Ciência da Implementação , Saúde Pública/educação , Currículo , Humanos , North Carolina , Competência Profissional/normas , Faculdades de Medicina
9.
PLoS Negl Trop Dis ; 13(3): e0007267, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30908495

RESUMO

INTRODUCTION: The Global Strategy to Eliminate Lymphatic Filiariasis (GFELF) through Mass Drug Administration (MDA) has been implemented in Ghana since the year 2000 and transmission has been interrupted in 76 of 98 endemic districts. To improve the MDA in the remaining districts with microfilaria (MF) prevalence above the 1% threshold for the interruption of transmission, there is a need to identify and implement appropriate quality improvement (QI) strategies. This paper describes the use of intervention mapping to select QI strategies to improve an existing evidence-based MDA program in Northern Ghana. METHODS: Due to the complexities associated with implementing evidence-based programs (EBP) such as the lymphatic filariasis MDA and variability in the context, an initial assessment to identify implementation bottlenecks associated with the quality of implementation of lymphatic filariasis MDA in the Bole District of Ghana was conducted using a mixed methods approach. Based on the findings of the initial assessment, a context specific QI strategy was designed and operationalized using intervention mapping strategy in terms of seven domains: actor, the action, action targets, temporality, dose, implementation outcomes addressed, and theoretical justification. RESULTS: The initial needs assessment shows that the persistent transmission of lymphatic filariasis in the Bole District is characterized by high levels of refusal to ingest the drug, high levels of reported adverse drug reactions, low MDA coverage at community level, poor adherence to the MDA protocol and non-participants' responsiveness. CONCLUSION: This study has shown that it is feasible to develop a context specific QI strategy for an existing evidence-based intervention based on an initial needs assessment through stakeholder participation using the IM approach. However, working (towards) QI requires more time than is usually available in public health service. Sufficient theoretical knowledge of implementation research and experience with technical IM experts must be available.


Assuntos
Filariose Linfática/prevenção & controle , Administração Massiva de Medicamentos , Melhoria de Qualidade , Adulto , Animais , Erradicação de Doenças , Filariose Linfática/tratamento farmacológico , Filariose Linfática/epidemiologia , Filariose Linfática/parasitologia , Feminino , Gana/epidemiologia , Humanos , Masculino , Microfilárias , Pessoa de Meia-Idade , Prevalência
10.
BMC Med Educ ; 19(1): 52, 2019 Feb 11.
Artigo em Inglês | MEDLINE | ID: mdl-30744625

RESUMO

BACKGROUND: Frontline healthcare workers are critical to meeting the maternal, newborn and child health Sustainable Development Goals in low- and middle-income countries. The World Health Organization has identified leadership development as integral to achieving successful health outcomes, but few programs exist for frontline healthcare workers in low-resource settings. METHODS: An 18-month pilot leadership development program was designed and implemented at Greater Accra Regional Hospital, a tertiary care facility in Ghana. A multi-modal training approach was utilized to include individual coaching, participatory discussions, role plays, and didactic sessions on leadership styles, emotional intelligence, communication, accountability and compassionate care. RESULTS: A cross-section of 140 staff from 8 distinct hospital wards and 19 ranks were involved in various components of the leadership program from January 2014 to June 2015. At baseline, the primary leadership challenges and goals of the staff included: interpersonal communication, institutional logistics, compliance, efficiency and staff attitudes. Thirteen participants developed a total of 17 leadership projects to apply their training, many of which focused on improving challenges in organizational culture and systems through bettering leadership skills and interpersonal communication. The staff highly valued the program and found it beneficial to their work. CONCLUSIONS: Self-selected individual leadership projects mirrored areas of concern found in the needs assessment, indicating that the program was successful in achieving its goals. The on-site nature of the program was cost-effective and led to maximum staff participation despite clinical responsibilities. A longstanding relationship between the design team and the local hospital staff allowed for an exploration of approaches, many of which were new to the local context. Further research is needed on adapting the program to other settings in Ghana and integrating it into broader systems strengthening interventions. This pilot program was well received and warrants further adaptation and scale up.


Assuntos
Pessoal de Saúde/educação , Liderança , Serviços de Saúde Materno-Infantil/organização & administração , Melhoria de Qualidade/organização & administração , Centros de Atenção Terciária , Adulto , Atitude do Pessoal de Saúde , Fortalecimento Institucional , Protocolos Clínicos , Feminino , Gana/epidemiologia , Humanos , Recém-Nascido , Masculino , Serviços de Saúde Materno-Infantil/normas , Determinação de Necessidades de Cuidados de Saúde , Projetos Piloto , Gravidez , Desenvolvimento de Programas , Avaliação de Programas e Projetos de Saúde
11.
Cult Med Psychiatry ; 43(1): 160-180, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30105653

RESUMO

Depression is highly prevalent and the cause of considerable suffering for peoples across the globe. Case finding for depression is challenging because individuals often do not recognize the symptoms in themselves or may resist the diagnosis as a result of cultural stigma. Screening instruments, to be accurate, must be valid in the particular setting in which they are being applied, and diagnosis in primary care settings, is further made challenging because patients often present with a wide variety of somatic symptoms that could be medical. 115 women were screened for depression in this study in one community in Uganda, and 87 were found to be depressed using the SRQ-20. The cognitive impairment and decreased energy sub-scales of the SRQ-20 seemed to best differentiate for depression. We then interviewed the 87 women and found that, overwhelmingly, their complaints were somatic, and that their expectation for treatment was to receive medical tests and medications. Caregivers in primary care clinics in Uganda should know that in the reporting of their somatic symptoms patients may be trying to communicate more about themselves than just the state of their physical health; and that feelings of uselessness or of hopelessness when expressed by a patient should lead them to suspect severe mental illness since these symptoms were not found to be characteristic of the milder depression that is highly prevalent in Ugandan women.


Assuntos
Depressão/diagnóstico , Depressão/psicologia , Estigma Social , Adolescente , Adulto , Feminino , Humanos , Entrevistas como Assunto , Sintomas Inexplicáveis , Escalas de Graduação Psiquiátrica , Uganda , Mulheres/psicologia , Adulto Jovem
12.
Int J Health Plann Manage ; 34(1): e369-e386, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30216529

RESUMO

BACKGROUND: Effective implementation processes are essential in achieving desired outcomes of health initiatives. Whereas many approaches to implementation may seem straightforward, careful advanced planning, multiple stakeholder involvements, and addressing other contextual constraints needed for quality implementation are complex. Consequently, there have been recent calls for more theory-informed implementation science in health systems strengthening. This study applies the quality implementation framework (QIF) developed by Meyers, Durlak, and Wandersman to identify and explain observed implementation gaps in a primary health care system improvement intervention in Nigeria. METHODS: We conducted a retrospective process appraisal by analyzing contents of 39 policy document and 15 key informant interviews. Using the QIF, we assessed challenges in the implementation processes and quality of an improvement model across the tiers of Nigeria's decentralized health system. RESULTS: Significant process gaps were identified that may have affected subnational implementation quality. Key challenges observed include inadequate stakeholder engagements and poor fidelity to planned implementation processes. Although needs and fit assessments, organizational capacity building, and development of implementation plans at national level were relatively well carried out, these were not effective in ensuring quality and sustainability at the subnational level. CONCLUSIONS: Implementing initiatives between levels of governance is more complex than within a tier. Adequate preintervention planning, understanding, and engaging the various interests across the governance spectrum are key to improving quality.


Assuntos
Política , Atenção Primária à Saúde/normas , Melhoria de Qualidade/organização & administração , Fortalecimento Institucional , Política de Saúde , Entrevistas como Assunto , Nigéria , Pesquisa Qualitativa , Estudos Retrospectivos
13.
BMJ Glob Health ; 3(2): e000623, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29707245

RESUMO

Institutional delivery has been proposed as a method for reducing maternal morbidity and mortality, but little is known about how referral hospitals in low-resource settings can best manage the expected influx of patients. In this study, we assess the impact of an obstetric triage improvement programme on reducing hospital-based delay in a referral hospital in Accra, Ghana. An Active Implementation Framework is used to describe a 5-year intervention to introduce and monitor obstetric triage capabilities. Baseline data, collected from September to November 2012, revealed significant delays in patient assessment on arrival. A triage training course and monitoring of quality improvement tools occurred in 2013 and 2014. Implementation barriers led to the construction of a free-standing obstetric triage pavilion, opened January 2015, with dedicated midwives. Data were collected at three time intervals following the triage pavilion opening and compared with baseline including: referral indications, patient and labour characteristics, waiting time from arrival to assessment and the documentation of a care plan. An obstetric triage improvement programme reduced the median (IQR) patient waiting time from facility arrival to first assessment by a midwife from 40 min (15-100) to 5 min (2-6) (p<0.001) over the 5-year intervention. The triage pavilion enhanced performance resulting in the elimination of previous delays associated with the time of admission and disease acuity. Care plan documentation increased from 51% to 96%. Obstetric triage, when properly implemented, reduced delay in a busy, low-resource hospital. The implementation process was sustained under local leadership during transition to a new hospital.

14.
Health Policy Plan ; 33(6): 715-728, 2018 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-29741673

RESUMO

Quality improvement models have been applied across various levels of health systems with varying success leading to scepticisms about effectiveness. Health systems are complex, influenced by contexts and characterized by numerous interests. Thus, a shift in focus from examining whether improvement models work, to understanding why, when and where they work most effectively is essential. Nigeria introduced DIVA (Diagnose-Intervene-Verify-Adjust) as a model to strengthen decentralized PHC planning. However, implementation has been poorly sustained. This article explores the role of actors and context in implementation and sustainability of DIVA in two local government areas (LGAs) in Nigeria. We employed an integrated mixed method approach in which qualitative data was used in conjunction with quantitative to understand effects of actors and contexts on implementation outcomes. We analysed policy documents and conducted interviews with PHC managers. Then using the Model for Understanding Success in Quality (MUSIQ), we measured contextual factors affecting implementation of DIVA in the selected LGAs. The LGAs scored 117.42 and 104.67 out of 168 points on the MUSIQ scale, respectively, indicating contextual barriers exist. Both have strong DIVA team attributes, but these could not independently ensure quality implementation. Although external support accounted for the greatest contextual disparities, the utmost implementation challenges relate to subnational government leadership, management, financial and technical support. Although higher levels of government may set visionary goals for PHC, interventions are potentially skewed towards donor interests at lower (implementation) levels. Thus, subnational political will is a key determinant of quality implementation. Consequently, advocacy for responsible and accountable political governance is essential in comparable decentralized contexts.


Assuntos
Implementação de Plano de Saúde/métodos , Política , Atenção Primária à Saúde/organização & administração , Melhoria de Qualidade , Política de Saúde , Humanos , Entrevistas como Assunto , Nigéria , Pesquisa Qualitativa
15.
Int J Qual Health Care ; 30(9): 724-730, 2018 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-29788245

RESUMO

Quality issue: Low-resource clinical settings often face obstacles that challenge the implementation of recommended evidence-based practices (EBPs). Implementation science approaches are useful in identifying barriers and developing strategies to address them. Initial assessment: Ridge Regional Hospital (RRH), a tertiary referral hospital in Accra, Ghana experienced a spike in rates of neonatal sepsis and launched a quality improvement (QI) initiative that identified poor adherence to hand hygiene in the neonatal intensive care unit as a potential source of infections. Choice of solution: A multi-modal change package of World Health Organization-recommended solutions was created to address this issue. Implementation: To ensure that the outputs of the QI effort were adopted within the organization, leaders at RRH and Kybele, Inc. used an implementation science framework called the 'Interactive Systems Framework for Dissemination and Implementation' (ISF) to create a package of locally acceptable implementation strategies. The ISF has never been used before to guide implementation in low-resource settings. Evaluation: Hand hygiene compliance rose from 67% to 92% overall, including a 36% increase during the night shifts-a group of healthcare workers with typically very low levels of compliance. Lessons learned: The drastic improvement in adherence to hand hygiene suggests the potential value of the joint use of QI and implementation science to promote the creation and application of contextually appropriate EBPs in low-resource settings. Our results also suggest that using an implementation framework such as the ISF could rapidly increase the uptake of other evidence-based interventions in low-resource settings.


Assuntos
Infecção Hospitalar/prevenção & controle , Higiene das Mãos/organização & administração , Ciência da Implementação , Unidades de Terapia Intensiva Neonatal/normas , Gana , Fidelidade a Diretrizes , Pessoal de Saúde/psicologia , Humanos , Recém-Nascido , Controle de Infecções/métodos , Ensino , Centros de Atenção Terciária
16.
Rural Remote Health ; 18(2): 4570, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29804461

RESUMO

INTRODUCTION: Childcare centers (CCCs) with good quality standards can be effective in reducing the risk of diseases being easily spread from person to person. The aim of the present study's program, adapted from a method used by the United Nations Development Program, was to increase the capacity of local administrators(s) and heads of CCCs to improve quality standards. METHODS: This study was quasi-experimental, with a one group pretest-post-test design. In this study the authors describe the effects and impacts of the program in Chonburi Province in eastern Thailand. Six LAs and 48 CCC heads were trained regarding (1) knowledge of the Thai Department of Health quality standards, (2) implementation and assurance and (3) program evaluation. The program consisted of three sequential participatory workshops. Effects at the center level were increased overall knowledge of quality standards of CCCs (QCCC), and developed skills of improvement plans. The impact at the center level was CCCs achieving the QCCC. At the child level it was the reduction in the period prevalence of three diseases and two symptoms. RESULTS: The significant (p<0.05) effects and impacts at the center level were increased overall knowledge of QCCC in LAs and CCC heads and increased overall managerial skills of CCC heads. At the child level, the period prevalence of chickenpox and diarrhea symptom were reduced. CONCLUSION: Participatory capacity building is an appropriate way to enhance the managerial skills of LAs and heads of CCCs for improving quality of CCCs to meet the local authority and the Ministry of Public Health quality standards.


Assuntos
Fortalecimento Institucional/organização & administração , Creches/organização & administração , Melhoria de Qualidade/organização & administração , Adulto , Criança , Creches/normas , Pré-Escolar , Feminino , Humanos , Conhecimento , Avaliação de Programas e Projetos de Saúde , Tailândia
17.
Midwifery ; 61: 45-52, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29525248

RESUMO

OBJECTIVE: to introduce and embed a midwife-led obstetric triage system in a busy labour ward in Accra, Ghana to improve the quality of care and to reduce delay. DESIGN: the study utilized a participatory action research design. Local staff participated in baseline data collection, the triage training course design and delivery, and post-training monitoring and evaluation. SETTING: a regional referral hospital in Accra, Ghana undertaking 11,032 deliveries in 2012. PARTICIPANTS: all midwives and medical staff. MEASUREMENTS: measurements included maternal health outcomes, observations of labour ward activity, structured assessments of midwife actions during admission, waiting times, focus group discussions, and learning needs assessments which informed the course content. During training, two quality improvement tools were developed; coloured risk acuity wristbands and a one page triage assessment form. Participants measured compliance and accuracy in the use of these tools following course completion. FINDINGS: initially, no formal triage system was in place. The environment was chaotic with poor compliance to existing protocols. Sixty-two midwives received triage training between 2013 and 2014. Two Triage Champions became responsible for triage implementation, monitoring and further training. Following training, the 'in-charge' midwives recorded a cumulative average of 83.4% of women wearing coloured wristbands. A separate audit by the Triage Champions found that 495/535 (93%) of the wristbands were correctly applied based on the diagnosis. Quarterly monitoring of the triage assessment forms by Kybele trainers, showed that 92% recorded the risk acuity colour, 85% a 'working diagnosis' and 82% a 'plan.' Median (interquartile range) waiting times were reduced from 40 (15-100) to 29 (11-60) minutes (p = 007). Twenty of 25 of the staff reported that the wristbands were helpful. CONCLUSIONS: an interactive triage training course led to the development of a triage assessment form and the use of coloured patient wristbands which resulted in delay reduction and improved quality of maternity care.


Assuntos
Trabalho de Parto , Tocologia/métodos , Triagem/métodos , Adulto , Educação/métodos , Escolaridade , Feminino , Grupos Focais , Gana , Humanos , Masculino , Serviços de Saúde Materna , Pessoa de Meia-Idade , Tocologia/educação , Gravidez , Desenvolvimento de Programas/métodos , Melhoria de Qualidade , Triagem/tendências
18.
Int J Qual Health Care ; 30(suppl_1): 15-19, 2018 Apr 20.
Artigo em Inglês | MEDLINE | ID: mdl-29462325

RESUMO

During the Salzburg Global Seminar Session 565-'Better Health Care: How do we learn about improvement?', participants discussed the need to unpack the 'black box' of improvement. The 'black box' refers to the fact that when quality improvement interventions are described or evaluated, there is a tendency to assume a simple, linear path between the intervention and the outcomes it yields. It is also assumed that it is enough to evaluate the results without understanding the process of by which the improvement took place. However, quality improvement interventions are complex, nonlinear and evolve in response to local settings. To accurately assess the effectiveness of quality improvement and disseminate the learning, there must be a greater understanding of the complexity of quality improvement work. To remain consistent with the language used in Salzburg, we refer to this as 'unpacking the black box' of improvement. To illustrate the complexity of improvement, this article introduces four quality improvement case studies. In unpacking the black box, we present and demonstrate how Cynefin framework from complexity theory can be used to categorize and evaluate quality improvement interventions. Many quality improvement projects are implemented in complex contexts, necessitating an approach defined as 'probe-sense-respond'. In this approach, teams experiment, learn and adapt their changes to their local setting. Quality improvement professionals intuitively use the probe-sense-respond approach in their work but document and evaluate their projects using language for 'simple' or 'complicated' contexts, rather than the 'complex' contexts in which they work. As a result, evaluations tend to ask 'How can we attribute outcomes to the intervention?', rather than 'What were the adaptations that took place?'. By unpacking the black box of improvement, improvers can more accurately document and describe their interventions, allowing evaluators to ask the right questions and more adequately evaluate quality improvement interventions.


Assuntos
Garantia da Qualidade dos Cuidados de Saúde/organização & administração , Melhoria de Qualidade/organização & administração , Anemia/prevenção & controle , Lista de Checagem/métodos , Pré-Escolar , Feminino , Humanos , Índia , Disseminação de Informação , Mali , Cultura Organizacional , Alta do Paciente/normas , Cuidado Pré-Natal/métodos , Cuidado Pré-Natal/organização & administração , Cuidado Pré-Natal/normas , Avaliação de Programas e Projetos de Saúde , Reino Unido
19.
Artigo em Inglês | MEDLINE | ID: mdl-29387148

RESUMO

Background: Globally, there is a large treatment gap for people with mental disorders, and this gap is especially extreme in Low and Middle Income Countries. This gap can be potentially bridged by integrating evidenced based mental health interventions into primary care, but there is little knowledge about how to do this well, especially in countries with weak health systems. Research into the best implementation approaches is a priority, but in order to do so, it is first necessary to adapt implementation science principles and tools for mental health services in low resource settings. Results: The frameworks that have been used to implement evidence-based behavioral health and health care interventions in High Income Countries do not directly apply to contexts where resources and processes for service delivery and support do not exist. We propose an implementation approach for low resource settings, called design-focused implementation, emphasizing the design of delivery systems using systematic design methods as precursor to implementation in severely resource constrained environments. This approach draws from existing literature in design thinking, quality implementation, improvement science and evaluation and we describe its use in creating the processes, organizations and the enabling environment for integration of mental health service delivery into primary care in India. Conclusions: Design-focused implementation will be useful for guiding research and practice in closing the implementation gap for a wide variety of complex interventions in low resource settings.

20.
Int J Qual Health Care ; 30(suppl_1): 24-28, 2018 Apr 20.
Artigo em Inglês | MEDLINE | ID: mdl-29447351

RESUMO

The gap between implementers and researchers of quality improvement (QI) has hampered the degree and speed of change needed to reduce avoidable suffering and harm in health care. Underlying causes of this gap include differences in goals and incentives, preferred methodologies, level and types of evidence prioritized and targeted audiences. The Salzburg Global Seminar on 'Better Health Care: How do we learn about improvement?' brought together researchers, policy makers, funders, implementers, evaluators from low-, middle- and high-income countries to explore how to increase the impact of QI. In this paper, we describe some of the reasons for this gap and offer suggestions to better bridge the chasm between researchers and implementers. Effectively bridging this gap can increase the generalizability of QI interventions, accelerate the spread of effective approaches while also strengthening the local work of implementers. Increasing the effectiveness of research and work in the field will support the knowledge translation needed to achieve quality Universal Health Coverage and the Sustainable Development Goals.


Assuntos
Pesquisa sobre Serviços de Saúde , Melhoria de Qualidade/organização & administração , Pesquisa Médica Translacional , Conservação dos Recursos Naturais , Assistência à Saúde/organização & administração , Assistência à Saúde/normas , Humanos , Motivação , Objetivos Organizacionais , Desenvolvimento de Programas , Pesquisa Médica Translacional/métodos , Pesquisa Médica Translacional/organização & administração
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