Trends in non-pharmaceutical intervention (NPI) related community practice for the prevention of COVID-19 in Addis Ababa, Ethiopia.

BACKGROUND: The COVID-19 pandemic has affected Ethiopia since March 13, 2020, when the first case was detected in Addis Ababa. Since then, the incidence of cases has continued to increase day by day. As a result, the health sector has recommended universal preventive measures to be practiced by the public. However, studies on adherence to these preventive measures are limited. OBJECTIVE: To monitor the status of preventive practices of the population related to hand washing, physical distancing, and respiratory hygiene practices at selected sites within the city of Addis Ababa. METHODS: Weekly cross-sectional non-participatory observations were done during the period of April-June, 2020. Data was collected using the Open Data Kit (ODK) tool in ten public sites involving eight public facilities targeted for individual observations. Ten individuals were randomly observed at each facility over two days a week at peak hours of public services. WHO operational definitions of the preventive behaviors were adopted for this study. Observations were conducted anonymously at gates or entrances of public facilities and places. RESULTS: A total of 12,056 individual observations with 53% males and 82% in an estimated age range of 18-50 years age group were involved in this study. There was an increase in the practice of respiratory hygiene from 14% in week one to 77% in week 10, while those of hand hygiene and physical distancing changed little over the weeks from their baseline of 24% and 34%, respectively. Overall, respiratory hygiene demonstrated an increased rate of 6% per week, while hand hygiene and physical distancing had less than a 1% change per week, Females and the estimated age group of 18-50 years had practice changes in respiratory hygiene with no difference in hand hygiene and physical distancing practices. Respiratory hygiene took about six weeks to reach a level of 77% from its baseline of 24%, making an increment of about 9% per week. CONCLUSION: The public practice of respiratory hygiene improved threefold whereas hand hygiene and physical distancing revealed no change. Regularly sustained public mobilization and mass education are required to sustain the achievements gained in respiratory hygiene and further hand hygiene and physical distancing.

Rebuilding a US Federal Data Strategy After the End of the "Community Health Status Indicators".

For nearly 2 decades, the Community Health Status Indicators tool reliably supplied communities with standardized, local health data and the capacity for peer-community comparisons. At the same time, it created a large community of users who shared learning in addressing local health needs. The tool survived a transition from the Health Resources and Services Administration to the Centers for Disease Control and Prevention before being shuttered in 2017. While new community data tools have come online, nothing has replaced Community Health Status Indicators, and many stakeholders continue to clamor for something new that will enable local health needs assessments, peer comparisons, and creation of a community of solutions. The National Committee on Vital and Health Statistics heard from many stakeholders that they still need a replacement data source. (Am J Public Health. 2021;111(10):1865-1873. https://doi.org/10.2105/AJPH.2021.306437).

Feasibility of task-sharing with community health workers for the identification, emergency management and referral of women with pre-eclampsia, in Mozambique.

BACKGROUND: Maternal mortality is an important public health problem in low-income countries. Delays in reaching health facilities and insufficient health care professionals call for innovative community-level solutions. There is limited evidence on the role of community health workers in the management of pregnancy complications. This study aimed to describe the feasibility of task-sharing the initial screening and initiation of obstetric emergency care for pre-eclampsia/eclampsia from the primary healthcare providers to community health workers in Mozambique and document healthcare facility preparedness to respond to referrals. METHOD: The study took place in Maputo and Gaza Provinces in southern Mozambique and aimed to inform the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomized controlled trial. This was a mixed-methods study. The quantitative data was collected through self-administered questionnaires completed by community health workers and a health facility survey; this data was analysed using Stata v13. The qualitative data was collected through focus group discussions and in-depth interviews with various community groups, health care providers, and policymakers. All discussions were audio-recorded and transcribed verbatim prior to thematic analysis using QSR NVivo 10. Data collection was complemented by reviewing existing documents regarding maternal health and community health worker policies, guidelines, reports and manuals. RESULTS: Community health workers in Mozambique were trained to identify the basic danger signs of pregnancy; however, they have not been trained to manage obstetric emergencies. Furthermore, barriers at health facilities were identified, including lack of equipment, shortage of supervisors, and irregular drug availability. All primary and the majority of secondary-level facilities (57%) do not provide blood transfusions or have surgical capacity, and thus such cases must be referred to the tertiary-level. Although most healthcare facilities (96%) had access to an ambulance for referrals, no transport was available from the community to the healthcare facility. CONCLUSIONS: This study showed that task-sharing for screening and pre-referral management of pre-eclampsia and eclampsia were deemed feasible and acceptable at the community-level, but an effort should be in place to address challenges at the health system level.

Maternal mortality is an important public health problem in Mozambique. Delays in reaching health facilities and insufficient health care professionals call for innovative community-level solutions. We conducted a study to describe the feasibility of task-sharing the screening and initiation of management for pre-eclampsia/eclampsia from the primary healthcare providers to community health workers in Mozambique and to document healthcare facility preparedness to respond to referrals. The study was done to inform a future intervention trial known as the Community-Level Interventions for Pre-eclampsia (CLIP) study. We interviewed community health workers, women, various community groups, health care providers, and policymakers and assessed health facilities in Maputo and Gaza provinces, Mozambique. Our results showed that community health workers in Mozambique were trained to identify the basic danger signs of pregnancy; however, they were not trained or equipped to provide obstetric emergencies care prior to referral. Nurses at primary health facilities were supportive of task-sharing with community health workers; however, some barriers mentioned include a lack of equipment, shortage of supervisors, and irregular drug availability. Local stakeholders emphasized the need for comprehensive training and supervision of community health workers to take on new tasks. Task-sharing for screening and pre-referral management of pre-eclampsia and eclampsia was deemed feasible at the community level in southern Mozambique, but still, to be addressed some health system level barriers to the management of pregnancies complications.

The ability and safety of community-based health workers to safely initiate lifesaving therapies for pre-eclampsia in Ogun State, Nigeria: An analysis of 260 community treatments with MgSO4 and/or methyldopa.

OBJECTIVES: To evaluate community-based health workers' ability to identify cases of hypertension in pregnancy, safely deliver methyldopa and magnesium sulphate and make referrals when appropriate. STUDY DESIGN: This was part of Nigeria Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomized controlled trial (NCT01911494). Community-based Health Workers (CHW) recruited pregnant women from five Local Government Areas (clusters) and used mobile health aid for clinical assessment of pre-eclampsia. MAIN OUTCOME MEASURES: The primary outcome was the number of adverse events that occurred after the administration of magnesium sulphate and/or methyldopa to pregnant women by CHWs. FINDINGS: Of 8790 women receiving mobile health-guided care, community-based health workers in Nigeria provided 309 women with hypertension (4.2% of delivered women), and safely administered 142 doses of intramuscular magnesium sulphate. Community Heath Extension Workers (CHEWs) and nurses gave fifty-two and sixty-seven doses of intramuscular magnesium sulphate respectively, twenty-three doses were given by other health care workers (midwives, community health officers, health assistants). The high rate of administration by nurses can be explained by turf protection as well as their seniority within the health system. Also, CHEWs and nurses gave 124 doses of oral methyldopa and 126 urgent referrals were completed. There were no complications related to administration of treatment or referral. INTERPRETATION: These findings demonstrate the ability of community-based health workers to safely administer methyldopa and intramuscular magnesium sulphate. The use of task-sharing, therefore, could drastically reduce the three delays (triage, transport and treatment) associated with high maternal mortality and morbidity in rural communities in low- and middle-income countries.

The need for a balanced hospital-based care (HBC) and home- and community-based care (HCBC) approach for mitigating COVID-19 pandemic in sub-Saharan Africa.

The onslaught of COVID-19 pandemic has greatly overwhelmed some of the best healthcare systems in the world. Medical practitioners working in hospitals at the epicenters of COVID-19 pandemic have emphasized on the need to manage mildly ill and convalescent COVID-19 patients at home or community facilities rather than at hospitals during a pandemic. In this article, we highlight that a standardized home- and community-based (HCBC) approach for management of COVID-19 patients will be a key component for preparing hospitals in sub-Saharan Africa (SSA) for a potential surge in COVID-19 cases. So far, based on the trajectory of infection, we think that SSA seems to have a window of opportunity, albeit narrowing, for implementing HCBC. However, there are challenges that will need to be addressed in order to implement and maintain HCBC. Successful implementation and maintenance of HCBC in SSA will require international agencies and key donors to work closely with the national governments; providing them with policy, technical, and financial assistance. Home- and community-based care (HCBC) is also important because it can play a role in advocacy, education, training, and health promotion during COVID-19 pandemic. We further underscore the need for a delicate balance between HCBC and hospital-based care (HBC) approach as well as with COVID-19 mitigation and suppression measures in order to reduce the risk of SARS-CoV-2 community transmission and allow optimal continuity of the HBC. We conclude by emphasizing once again that, for countries in SSA to adequately prepare for the worst-case scenario of COVID-19 pandemic in the absence of a cure, policy makers of member states need to act collectively and fast.

Developing network adequacy standards for VA Community Care.

OBJECTIVES: To inform how the VA should develop and implement network adequacy standards, we convened an expert panel to discuss Community Care Network (CCN) adequacy and how VA might implement network adequacy standards for community care. DATA SOURCES/STUDY SETTING: Data were generated from expert panel ratings and from an audio-recorded expert panel meeting conducted in Arlington, Virginia, in October 2017. STUDY DESIGN: We used a modified Delphi panel process involving one round of expert panel ratings provided by nine experts in network adequacy standards. Expert panel members received a list of network adequacy standard measures used in commercial and government market and were provided a rating form listing a total of 11 measures and characteristics to rate. DATA COLLECTION METHODS: Items on the rating form were individually discussed during an expert panel meeting between the nine expert panel members and VA Office of Community Care leaders. Attendees addressed discordant views and generated revised or new standards accordingly. Recorded audio data were transcribed to facilitate thematic analysis regarding opportunities and challenges with implementing network adequacy standards in VA Community Care. PRINCIPAL FINDINGS: The five highest ranked standards were network directories for Veterans, regular reporting of network adequacy data to VA, maximum wait time/distance standards, minimum ratio of providers to enrolled population, and qualitative assessments of network adequacy. During the expert panel discussion with VA Community Care leaders, opportunities and challenges implementing network adequacy standards were highlighted. CONCLUSIONS: Our expert panel shed light on priorities for network adequacy to be implemented under CCN contracts, such as developing comprehensive provider directories for Veterans to use when selecting community providers. Remaining questions focus on whether the VA could reasonably develop and implement network adequacy standards given current Congressional restraints on VA reimbursement to community providers.

Harm Reduction for Adolescents and Young Adults During the COVID-19 Pandemic: A Case Study of Community Care in Reach.

The coronavirus disease 2019 (COVID-19) pandemic has challenged the ability of harm reduction programs to provide vital services to adolescents, young adults, and people who use drugs, thereby increasing the risk of overdose, infection, withdrawal, and other complications of drug use. To evaluate the effect of the COVID-19 pandemic on harm reduction services for adolescents and young adults in Boston, we conducted a quantitative assessment of the Community Care in Reach (CCIR) youth pilot program to determine gaps in services created by its closure during the peak of the pandemic (March 19-June 21, 2020). We also conducted semistructured interviews with staff members at 6 harm reduction programs in Boston from April 27 through May 4, 2020, to identify gaps in harm reduction services, changes in substance use practices and patterns of engagement with people who use drugs, and how harm reduction programs adapted to pandemic conditions. During the pandemic, harm reduction programs struggled to maintain staffing, supplies, infection control measures, and regular connection with their participants. During the 3-month suspension of CCIR mobile van services, CCIR missed an estimated 363 contacts, 169 units of naloxone distributed, and 402 syringes distributed. Based on our findings, we propose the following recommendations for sustaining harm reduction services during times of crisis: pursuing high-level policy changes to eliminate political barriers to care and fund harm reduction efforts; enabling and empowering harm reduction programs to innovatively and safely distribute vital resources and build community during a crisis; and providing comprehensive support to people to minimize drug-related harms.

Home- and Community-Based Provider Preparation for Pennsylvania's Managed Long-term Services and Supports.

As Pennsylvania implements its managed long-term services and supports program, we explore how home- and community-based providers are preparing for and perceiving the transition through an online survey. We summarize responses and conduct chi-square analysis to measure differences between select provider groups. Despite high levels of uncertainty about program impact, over 84% of respondents plan to participate. We found that providers in the first implementation phase had more strategic and operational discussions with MCOs than the other two phases (p < .03). As program rollout continues, we anticipate changes in MCO-provider conversation frequency and topics based upon implementation zone.

Implementing Continuous Quality Improvement in an Integrated Community Urology Practice: Lessons Learned.

OBJECTIVE: To determine the effectiveness of 2 different continuous quality improvement interventions in an integrated community urology practice. We specifically assessed the impact of audited physician feedback on improving physicians' adoption of active surveillance for low-risk prostate cancer (CaP) and adherence to a prostate biopsy time-out intervention. MATERIALS AND METHODS: The electronic medical records of Genesis Healthcare Partners were analyzed between August 24, 2011 and September 30, 2020 to evaluate the performance of 2 quality interventions: audited physician feedback to improve active surveillance adoption in low-risk CaP patients, and audited physician feedback to promote adherence to an electronic medical records embedded prostate biopsy time-out template. Physician and Genesis Healthcare Partners group adherence to each quality initiative was compared before and after each intervention type using ANOVA testing. RESULTS: For active surveillance, we consistently saw an increase in active surveillance adoption for low risk CaP patients in association with continuous audited feedback (P < .001). Adherence to the prostate biopsy time-out template improved when audited feedback was provided (P < .001). CONCLUSION: The implementation of clinical guidelines into routine clinical practice remains challenging and poses an obstacle to the improvement of United States healthcare quality. Continuous quality improvement should be a dynamic process, and in our experience, audited feedback coupled with education is most effective.

Multi-stage Screening in Early Intervention: A Critical Strategy for Improving ASD Identification and Addressing Disparities.

Health disparities in ASD detection affect children's access to subsequent interventions. We examined potential disparities in implementation of a multi-stage ASD screening and diagnostic evaluation protocol in Part C Early Intervention with 4943 children ages 14-36 months (mean 22.0 months; 62.9% boys, 73.3% children of color, 34.9% non-English-primary language, 64.5% publicly-insured). Participation and follow-through were high (64.9% and 65.3% at first- and second-stage screening, respectively, 84.6% at diagnostic evaluation). Logistic regressions identified predictors of screening participation and outcomes at each stage; demographic differences (race, language, public insurance) were observed only at first-stage screening and reflected higher participation for children of color and higher positive screens for publicly-insured children. Results suggest the multi-stage screening protocol shows promise in addressing disparities in early diagnosis.

Telehealth and the Community SMI Population: Reflections on the Disrupter Experience of COVID-19.

The novel coronavirus pandemic and the resulting expanded use of telemedicine have temporarily transformed community-based care for individuals with serious mental illness (SMI), challenging traditional treatment paradigms. We review the rapid regulatory and practice shifts that facilitated broad use of telemedicine, the literature on the use of telehealth and telemedicine for individuals with SMI supporting the feasibility/acceptability of mobile interventions, and the more limited evidence-based telemedicine practices for this population. We provide anecdotal reflections on the opportunities and challenges for telemedicine drawn from our daily experiences providing services and overseeing systems for this population during the pandemic. We conclude by proposing that a continued, more prominent role for telemedicine in the care of individuals with SMI be sustained in the post-coronavirus landscape, offering future directions for policy, technical assistance, training, and research to bring about this change.

Supporting Newly Identified or Diagnosed Autistic Adults: An Initial Evaluation of an Autistic-Led Programme.

Sixteen adults (diagnosed or self-identified as autistic) participated in one of two iterations of a ten-week autistic-led programme, aimed at helping autistic adults learn more about autism within a peer group context. Motivations for taking part in the programme included a desire for: (1) exploration of autism; (2) empowerment; and (3) the development of practical strategies and coping mechanisms. Interviews were conducted upon completion of the programme and again 6 months later. Using thematic analysis, three themes were identified: (1) appreciation of the autistic-led nature of the programme; (2) unity in diversity; and (3) developing a positive, practical outlook on autism. These promising initial results highlight the value of autistic-led peer support for those recently diagnosed/identified as autistic.

Proactive Risk Assessment through FMEA of Home Parenteral Nutrition Care Processes: A Survey Analysis.

BACKGROUND: Home Parenteral Nutrition (HPN) is a lifesaving clinical care process. However, undetected hazards and vulnerabilities in care transitions from hospital to community care may pose risk to patient's safety. Avoidable complications and adverse events may hinder the benefits of treatment. OBJECTIVE: The analysis carried out aims at framing through Human Factors and Ergonomics (HF/E) the critical issues for patient safety related to clinical care practices for HPN in healthcare organization. METHODS: We present the results of a proactive risk assessment analysis based on the FMEA methodology (Failure Mode and Effects Analysis) carried out in three different areas of the regional health care system of Tuscany, Italy. The clinical risk management and patient safety unit assessed the risk perception of Healthcare Workers (HWs) in regard to patient safety and situational awareness throughout the HPN patient journey. RESULTS: The analysis revealed heterogeneity in the Risk Priority Index (RPI) expressed by HWs. A lower RPI is associated with a HPN process that deploys in continuity between hospital care and community care. A higher RPI is associated with a quality and safety improvement process that is still ongoing. We also observed HWs expressing low RPI in the areas of the region where HPN has a hospital- focused approach and has limited adherence to patient safety requirements. Low RPI for HPN process may relate both to extensively deployed continuity of care and to jeopardized awareness on HPN phases and coordination. The analysis carried out enabled the definition of a common HPN workflow used as reference schema allowing for the definition of a set of recommendations for improving the quality and safety of the care processes. Moreover, the outcome of the proactive risk assessment laid the groundwork for the advancement of the patient safety regional requirements. CONCLUSION: The analysis had the role of promoting the contextualization of the culture of quality and safety within the HPN process resulting in an improved awareness of the criticalities and the role of nutrition units throughout the care process.

Innovative COVID-19 Programs to Rapidly Serve New Mexico : Project ECHO.

Project ECHO (Extension for Community Healthcare Outcomes) at the University of New Mexico is a telementoring program that uses videoconferencing technology to connect health care providers in underserved communities with subject matter experts. In March 2020, Project ECHO created 10 coronavirus disease 2019 (COVID-19) telementoring programs to meet the public health needs of clinicians and teachers living in underserved rural and urban regions of New Mexico. The newly created COVID-19 programs include 7 weekly sessions (Community Health Worker [in English and Spanish], Critical Care, Education, First-Responder Resiliency, Infectious Disease Office Hours, and Multi-specialty) and 3 one-day special sessions. We calculated the total number of attendees, along with the range and standard deviation, per session by program. Certain programs (Critical Care, Infectious Disease Office Hours, Multi-specialty) recorded the profession of attendees when available. The Project ECHO research team collected COVID-19 infection data by county from March 11 through May 31, 2020. During that same period, 9765 health care and general education professionals participated in the COVID-19 programs, and participants from 31 of 35 (89%) counties in New Mexico attended the sessions. Our initial evaluation of these programs demonstrates that an interprofessional clinician group and teachers used the Project ECHO network to build a community of practice and social network while meeting their educational and professional needs. Because of Project ECHO's large reach, the results of the New Mexico COVID-19 response suggest that the rapid use of ECHO telementoring could be used for other urgent national public health problems.

Indigenous communities' responses to the COVID-19 pandemic and consequences for maternal and neonatal health in remote Peruvian Amazon: a qualitative study based on routine programme supervision.

AIM: To explore indigenous communities' responses to the COVID-19 pandemic and its consequences for maternal and neonatal health (MNH) care in the Peruvian Amazon. METHODS: Mamás del Río is a community-based, MNH programme with comprehensive supervision covering monthly meetings with community health workers (CHW), community leaders and health facilities. With the onset of the lockdown, supervisors made telephone calls to discuss measures against COVID-19, governmental support, CHW activities in communities and provision of MNH care and COVID-19 preparedness at facilities. As part of the programme's ongoing mixed methods evaluation, we analysed written summaries of supervisor calls collected during the first 2 months of Peru's lockdown. RESULTS: Between March and May 2020, supervisors held two rounds of calls with CHWs and leaders of 68 communities and staff from 17 facilities. Most communities banned entry of foreigners, but about half tolerated residents travelling to regional towns for trade and social support. While social events were forbidden, strict home isolation was only practised in a third of communities as conflicting with daily routine. By the end of April, first clusters of suspected cases were reported in communities. COVID-19 test kits, training and medical face masks were not available in most rural facilities. Six out of seven facilities suspended routine antenatal and postnatal consultations while two-thirds of CHWs resumed home visits to pregnant women and newborns. CONCLUSIONS: Home isolation was hardly feasible in the rural Amazon context and community isolation was undermined by lack of external supplies and social support. With sustained community transmission, promotion of basic hygiene and mask use becomes essential. To avoid devastating effects on MNH, routine services at facilities need to be urgently re-established alongside COVID-19 preparedness plans. Community-based MNH programmes could offset detrimental indirect effects of the pandemic and provide an opportunity for local COVID-19 prevention and containment.