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1.
Lancet ; 396(10250): 553-563, 2020 08 22.
Artigo em Inglês | MEDLINE | ID: mdl-32828187

RESUMO

BACKGROUND: To overcome the three delays in triage, transport and treatment that underlie adverse pregnancy outcomes, we aimed to reduce all-cause adverse outcomes with community-level interventions targeting women with pregnancy hypertension in three low-income countries. METHODS: In this individual participant-level meta-analysis, we de-identified and pooled data from the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised controlled trials in Mozambique, Pakistan, and India, which were run in 2014-17. Consenting pregnant women, aged 12-49 years, were recruited in their homes. Clusters, defined by local administrative units, were randomly assigned (1:1) to intervention or control groups. The control groups continued local standard of care. The intervention comprised community engagement and existing community health worker-led mobile health-supported early detection, initial treatment, and hospital referral of women with hypertension. For this meta-analysis, as for the original studies, the primary outcome was a composite of maternal or perinatal outcome (either maternal, fetal, or neonatal death, or severe morbidity for the mother or baby), assessed by unmasked trial surveillance personnel. For this analysis, we included all consenting participants who were followed up with completed pregnancies at trial end. We analysed the outcome data with multilevel modelling and present data with the summary statistic of adjusted odds ratios (ORs) with 95% CIs (fixed effects for maternal age, parity, maternal education, and random effects for country and cluster). This meta-analysis is registered with PROSPERO, CRD42018102564. FINDINGS: Overall, 44 clusters (69 330 pregnant women) were randomly assigned to intervention (22 clusters [36 008 pregnancies]) or control (22 clusters [33 322 pregnancies]) groups. 32 290 (89·7%) pregnancies in the intervention group and 29 698 (89·1%) in the control group were followed up successfully. Median maternal age of included women was 26 years (IQR 22-30). In the intervention clusters, 6990 group and 16 691 home-based community engagement sessions and 138 347 community health worker-led visits to 20 819 (57·8%) of 36 008 women (of whom 11 095 [53·3%] had a visit every 4 weeks) occurred. Blood pressure and dipstick proteinuria were assessed per protocol. Few women were eligible for methyldopa for severe hypertension (181 [1%] of 20 819) or intramuscular magnesium sulfate for pre-eclampsia (198 [1%]), of whom most accepted treatment (162 [89·5%] of 181 for severe hypertension and 133 [67·2%] of 198 for pre-eclampsia). 1255 (6%) were referred to a comprehensive emergency obstetric care facility, of whom 864 (82%) accepted the referral. The primary outcome was similar in the intervention (7871 [24%] of 32 290 pregnancies) and control clusters (6516 [22%] of 29 698; adjusted OR 1·17, 95% CI 0·90-1·51; p=0·24). No intervention-related serious adverse events occurred, and few adverse effects occurred after in-community treatment with methyldopa (one [2%] of 51; India only) and none occurred after in-community treatment with magnesium sulfate or during transport to facility. INTERPRETATION: The CLIP intervention did not reduce adverse pregnancy outcomes. Future community-level interventions should expand the community health worker workforce, assess general (rather than condition-specific) messaging, and include health system strengthening. FUNDING: University of British Columbia, a grantee of the Bill & Melinda Gates Foundation.


Assuntos
Pré-Eclâmpsia/epidemiologia , Resultado da Gravidez/epidemiologia , Adolescente , Adulto , Criança , Serviços de Saúde Comunitária/normas , Feminino , Humanos , Índia/epidemiologia , Morte Materna/estatística & dados numéricos , Pessoa de Meia-Idade , Moçambique/epidemiologia , Paquistão/epidemiologia , Pré-Eclâmpsia/diagnóstico , Pré-Eclâmpsia/terapia , Gravidez , Ensaios Clínicos Controlados Aleatórios como Assunto , Adulto Jovem
10.
PLoS One ; 15(1): e0227351, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31923240

RESUMO

INTRODUCTION: Iron and Folic Acid Supplementation (IFAS) is an essential and affordable intervention strategy for prevention of anaemia during pregnancy. The supplements are currently provided for free to pregnant women in Kenya during antenatal care (ANC), but compliance remains low over the years. There is need for diversification of IFAS programme implementation by exploring other distribution channels to complement existing antenatal distribution and ensure consistent access to IFAS supplements. OBJECTIVES: To determine the effect of a community-based approach of IFAS distribution on compliance and assess side-effects experienced and their mitigation by pregnant women in Kiambu County. METHODOLOGY: A pretest-posttest quasi-experimental study design was used, consisting of an intervention and a control group, among 340 pregnant women 15-49 years, in five health facilities in Lari Sub-County in Kiambu County, between June 2016 and March 2017. Community health volunteers provided IFAS supplements, counselling and weekly follow-up to pregnant women in the intervention group while the control group followed standard practice from health facilities. Baseline and endline data were collected during antenatal care and compared. Quantitative data was analyzed using STATA version 14. Analysis of effect of intervention was done using Difference-In-Difference regression approach. RESULTS: Levels of compliance increased by 8% in intervention group and 6% in control group. There was increased awareness of IFAS side-effects across groups. The intervention group reported experiencing less side-effects and were better able to manage them compared to the control group. CONCLUSION: Implementation a community-based approach improved maternal compliance with IFAS, awareness of IFAS side effects and their management, with better improvement being recorded in the intervention group. Hence, there is need to integrate community-based approach with antenatal distribution of IFAS to improve supplementation.


Assuntos
Anemia/prevenção & controle , Ácido Fólico/uso terapêutico , Ferro/uso terapêutico , Gestantes , Adolescente , Adulto , Estudos de Casos e Controles , Serviços de Saúde Comunitária/normas , Suplementos Nutricionais , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Quênia , Pessoa de Meia-Idade , Cooperação do Paciente , Gravidez , Cuidado Pré-Natal , Adulto Jovem
12.
BMC Health Serv Res ; 19(1): 815, 2019 Nov 08.
Artigo em Inglês | MEDLINE | ID: mdl-31703678

RESUMO

BACKGROUND: Around the world, many healthcare organizations engage patients as a quality improvement strategy. In Canada, the University of Montreal has developed a model which consists in partnering with patient advisors, providers, and managers in quality improvement. This model was introduced through its Partners in Care Programs tested with several quality improvement teams in Quebec, Canada. Partnering with patients in quality improvement brings about new challenges for healthcare managers. This model is recent, and little is known about how managers contribute to implementing and sustaining it using key practices. METHODS: In-depth multi-level case studies were conducted within two healthcare organizations which have implemented a Partners in Care Program in quality improvement. The longitudinal design of this research enabled us to monitor the implementation of patient partnership initiatives from 2015 to 2017. In total, 38 interviews were carried out with managers at different levels (top-level, mid-level, and front-line) involved in the implementation of Partners in Care Programs. Additionally, seven focus groups were conducted with patients and providers. RESULTS: Our findings show that managers are engaged in four main types of practices: 1-designing the patient partnership approach so that it makes sense to the entire organization; 2-structuring patient partnership to support its deployment and sustainability; 3-managing patient advisor integration in quality improvement to avoid tokenistic involvement; 4-evaluating patient advisor integration to support continuous improvement. Designing and structuring patient partnership are based on typical management practices used to implement change initiatives in healthcare organizations, whereas managing and evaluating patient advisor integration require new daily practices from managers. Our results reveal that managers at all levels, from top to front-line, are concerned with the implementation of patient partnership in quality improvement. CONCLUSION: This research adds empirical support to the evidence regarding daily managerial practices used for implementing patient partnership initiatives in quality improvement and contributes to guiding healthcare organizations and managers when integrating such approaches.


Assuntos
Administração de Serviços de Saúde/normas , Relações Profissional-Paciente , Melhoria de Qualidade/organização & administração , Serviços de Saúde Comunitária/normas , Hospitais/normas , Humanos , Estudos Longitudinais , Quebeque
13.
Artigo em Inglês | MEDLINE | ID: mdl-31627474

RESUMO

Rural medical services play an important role in protecting and promoting the health of the rural population; however, patient satisfaction with rural medical services has been understudied in China. A better understanding of the actual situation and the determinants involved will provide evidence for health-related policy makers and hospital managers to further improve rural medical services. A total of 9811 patients (5208 outpatients and 4603 inpatients) were included in this study from a cross-sectional survey conducted in rural hospitals from 11 western provinces in China. Three in five patients (including outpatients and inpatients) were satisfied with rural medical services. The mean overall satisfaction scores were 3.61 ± 0.857 and 3.80 ± 0.829 (out of a maximum of 5) for rural outpatients and inpatients, respectively. The most satisfying domains for outpatients and inpatients were medical service attitude and illness explanation, and waiting time and medical expenses were the domains that outpatients and inpatients were least satisfied with. Satisfaction with medical technology (OR: 1.73; 95% CI: 1.57-1.92) and satisfaction with trust in physicians (OR: 2.05; 95% CI: 1.85-2.28) were identified as the strongest predictors of outpatients' and inpatients' overall satisfaction with rural medical services, respectively. This study might shed light on rural medical services management in China.


Assuntos
Serviços de Saúde Comunitária/estatística & dados numéricos , Serviços de Saúde Comunitária/normas , Pacientes Ambulatoriais/estatística & dados numéricos , Satisfação do Paciente/estatística & dados numéricos , População Rural , Adulto , China , Estudos Transversais , Feminino , Humanos , Pacientes Internados , Masculino , Pessoa de Meia-Idade , Inquéritos e Questionários
14.
CA Cancer J Clin ; 69(6): 468-484, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31617590

RESUMO

Multiple organizations around the world have issued evidence-based exercise guidance for patients with cancer and cancer survivors. Recently, the American College of Sports Medicine has updated its exercise guidance for cancer prevention as well as for the prevention and treatment of a variety of cancer health-related outcomes (eg, fatigue, anxiety, depression, function, and quality of life). Despite these guidelines, the majority of people living with and beyond cancer are not regularly physically active. Among the reasons for this is a lack of clarity on the part of those who work in oncology clinical settings of their role in assessing, advising, and referring patients to exercise. The authors propose using the American College of Sports Medicine's Exercise Is Medicine initiative to address this practice gap. The simple proposal is for clinicians to assess, advise, and refer patients to either home-based or community-based exercise or for further evaluation and intervention in outpatient rehabilitation. To do this will require care coordination with appropriate professionals as well as change in the behaviors of clinicians, patients, and those who deliver the rehabilitation and exercise programming. Behavior change is one of many challenges to enacting the proposed practice changes. Other implementation challenges include capacity for triage and referral, the need for a program registry, costs and compensation, and workforce development. In conclusion, there is a call to action for key stakeholders to create the infrastructure and cultural adaptations needed so that all people living with and beyond cancer can be as active as is possible for them.


Assuntos
Terapia por Exercício/métodos , Oncologia/métodos , Neoplasias/prevenção & controle , Neoplasias/reabilitação , Serviços de Saúde Comunitária/métodos , Serviços de Saúde Comunitária/normas , Prestação Integrada de Cuidados de Saúde/métodos , Prestação Integrada de Cuidados de Saúde/normas , Terapia por Exercício/normas , Humanos , Oncologia/normas , Neoplasias/complicações , Neoplasias/psicologia , Guias de Prática Clínica como Assunto
15.
BMC Health Serv Res ; 19(1): 699, 2019 Oct 15.
Artigo em Inglês | MEDLINE | ID: mdl-31615484

RESUMO

BACKGROUND: Dengue is an emerging vector disease with frequent outbreaks in Nepal that pose a major threat to public health. Dengue control activities are mostly outbreak driven, and still lack systematic interventions while most people have poor health-related knowledge and practices. Mobile Short Message Service (SMS) represents a low-cost health promotion intervention that can enhance the dengue prevention knowledge and practices of the affected communities. This study aimed to explore the acceptability, appropriateness, and effectiveness of mobile SMS intervention in improving dengue control practices. METHODS: This study was an implementation research that used mixed-methods design with intervention. A total of 300 households were divided into three groups, i.e. one control group, one dengue prevention leaflet (DPL) only intervention group and one DPL with mobile SMS intervention group (DPL + SMS). We used a structured questionnaire to collect information regarding participants' knowledge and practice of dengue prevention. We conducted in-depth interviews with key informants to measure acceptability and appropriateness of intervention. Mean difference with standard deviation (SD), one-way ANOVA, paired t-test and regression analyses were used to assess the effectiveness of the interventions. Thematic analysis was used to assess the acceptability, and appropriateness as well as barriers and enablers of the intervention. RESULTS: The DPL + SMS intervention produced significantly higher mean knowledge difference (32.7 ± 13.7 SD vs. 13.3 ± 8.8 SD) and mean practice difference (27.9 ± 11.4 SD vs 4.9 ± 5.4 SD) compared to the DPL only group (p = 0.000). Multivariate analysis showed that the DPL + SMS intervention was effective to increase knowledge by 28.6 points and practice by 28.1 points compared to the control group. The intervention was perceived as acceptable and appropriate by the study participants and key stakeholders. Perceived barriers included reaching private network users and poor network in geographically remote areas, while enabling factors included mobile phone penetration, low cost, and shared responsibility. CONCLUSIONS: Mobile SMS is an effective, acceptable and appropriate health intervention to improve dengue prevention practices in communities. This intervention can be adopted as a promising tool for health education against dengue and other diseases.


Assuntos
Telefone Celular/estatística & dados numéricos , Dengue/prevenção & controle , Promoção da Saúde/métodos , Adulto , Análise de Variância , Serviços de Saúde Comunitária/métodos , Serviços de Saúde Comunitária/normas , Feminino , Nível de Saúde , Humanos , Masculino , Nepal , Projetos Piloto , Inquéritos e Questionários , Envio de Mensagens de Texto/estatística & dados numéricos
17.
Phys Med Rehabil Clin N Am ; 30(4): 709-721, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31563164

RESUMO

Community-based rehabilitation (CBR) has changed considerably over 4 decades, resulting in a rights-based approach, holding local authorities accountable for service delivery. For medical rehabilitation in low-resource countries, there is concern about how this service gap will be covered. The CBR community continues to strengthen the evidence base for CBR implementation, acknowledging its extensiveness and variety on the ground. The creation of standardizing tools favors this process because it provides the building blocks to scale up, setting standards for implementation research. Finally, an International Classification of Functioning, Disability, and Health-based assessment and intervention model for CBR is proposed.


Assuntos
Serviços de Saúde Comunitária/normas , Países em Desenvolvimento , Pessoas com Deficiência/reabilitação , Classificação Internacional de Funcionalidade, Incapacidade e Saúde/normas , Reabilitação/normas , Humanos , Organização Mundial da Saúde
18.
Appl Ergon ; 81: 102876, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31422257

RESUMO

Back pain is a very common health problem and affects people across the world. This study applies an Inclusive Design approach to a community-based back pain service to understand the challenges, in relation to patients' capabilities, that can affect their access to the service. It consisted of three steps: i) online surveys and interviews with physiotherapists and collected patients' personal online care stories to gather insight into their experiences within the back pain care journeys; ii) estimated services' demands made on patients when they access the service and identified the related challenges and iii) proposed recommendations that could address the challenges for patients to access the service. The study suggests an Inclusive Design approach could help identify capability-related challenges such as vision and memory which could affect people's access to back pain treatment. In addition, the application of the approach also uncovered some non-capability-related challenges.


Assuntos
Dor nas Costas/terapia , Serviços de Saúde Comunitária/organização & administração , Procedimentos Clínicos/organização & administração , Acesso aos Serviços de Saúde/organização & administração , Necessidades e Demandas de Serviços de Saúde/organização & administração , Adulto , Serviços de Saúde Comunitária/normas , Procedimentos Clínicos/normas , Feminino , Acesso aos Serviços de Saúde/normas , Humanos , Masculino , Melhoria de Qualidade
19.
Br J Community Nurs ; 24(8): 370-376, 2019 Aug 02.
Artigo em Inglês | MEDLINE | ID: mdl-31369304

RESUMO

Community nurses are expected to deliver evidence-based practice, which is challenging given the diversity and breadth of the evidence base from which they can draw. This study aimed to explore community nurses' experiences of implementing change in their practice. Qualitative semi-structured interviews (n=9) and focus groups (n=2) with community nurses (n=17) were conducted. Three pathways to introduce change in practice were identified by participants: bottom-up, top-down and collaborative pathways. These are based on the nature of the proposed change, the available evidence, 'buy in' from colleagues and issues around implementation. The findings identify approaches to implementing change in community nursing practice. Practitioners would benefit from support to navigate the complex process of change through managerial support, ongoing education, accessible online resources and support through a practice development role.


Assuntos
Competência Clínica/normas , Serviços de Saúde Comunitária/normas , Enfermagem Baseada em Evidências/normas , Guias como Assunto , Papel do Profissional de Enfermagem , Inovação Organizacional , Medicina Estatal/normas , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pesquisa Qualitativa , Escócia
20.
Int J Tuberc Lung Dis ; 23(7): 844-849, 2019 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-31439117

RESUMO

SETTING: Efficient tuberculosis (TB) active case-finding strategies are important in settings with high TB burdens and limited resources, such as those in western Kenya.OBJECTIVE: To guide efforts to optimize screening efficiency, we identified the predictors of TB among people screened in health facilities and communities.DESIGN: During February 2015-June 2016, adults aged ≥15 years reporting any TB symptom were identified in health facilities and community mobile screening units, and evaluated for TB. We assessed the predictors of TB using a modified Poisson regression with generalized estimating equations to account for clustering according to screening site.RESULTS: TB was diagnosed in 484 (20.3%) of 2394 symptomatic adults in health facilities and 39 (3.4%) of 1424 in communities. In health facilities, >10% of symptomatic adults in all demographic groups had TB, and no predictors were associated with a ≥2-fold increased risk. In communities, the independent predictors of TB were male sex (adjusted prevalence ratio [aPR] = 4.26, 95%CI 2.43-7.45), HIV infection (aPR 2.37, 95%CI 1.18-4.77), and household TB contact in the last 2 years (aPR 2.84, 95%CI 1.62-4.96).CONCLUSION: Our findings support the notion of general TB screening in health facilities and evaluation of the adult household contacts of TB patients.


Assuntos
Acesso aos Serviços de Saúde , Programas de Rastreamento/normas , Tuberculose Pulmonar/prevenção & controle , Adolescente , Adulto , Serviços de Saúde Comunitária/normas , Comorbidade , Feminino , Infecções por HIV , Instalações de Saúde/normas , Humanos , Quênia/epidemiologia , Masculino , Pessoa de Meia-Idade , Análise de Regressão , Fatores Sexuais , Tuberculose Pulmonar/epidemiologia , Tuberculose Pulmonar/microbiologia , Adulto Jovem
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