Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 4.089
Filtrar
1.
BMC Health Serv Res ; 19(1): 878, 2019 Nov 21.
Artigo em Inglês | MEDLINE | ID: mdl-31752869

RESUMO

BACKGROUND: Community Health Workers (CHWs) are critical to providing healthcare services in countries such as India which face a severe shortage of skilled healthcare personnel especially in rural areas. The aim of this study is to understand the work flow of CHWs in a rural Community Mental Health Project (CMHP) in India and identify inefficiencies which impede their service delivery. This will aid in formulating a targeted policy approach, improving efficiency and supporting appropriate work allocation as the roles and responsibilities of the CHWs evolve. METHODS: A continuous observation Time Motion study was conducted on Community Health Workers selected through purposive sampling. The CHWs were observed for the duration of an entire working day (9 am- 3 pm) for 5 days each, staggered during a period of 1 month. The 14 different activities performed by the CHWs were identified and the time duration was recorded. Activities were then classified as value added, non-value added but necessary and non-value-added to determine their time allocation. RESULTS: Home visits occupied the CHWs for the maximum number of hours followed by Documentation, and Traveling. Documentation, Administrative work and Review of work process are the non-value-added but necessary activities which consumed a significant proportion of their time. The CHWs spent approximately 40% of their time on value added, 58.5% of their time on non-value added but necessary and 1.5% of their time on non-value added activities. The CHWs worked for 0.7 h beyond the stipulated time daily. CONCLUSION: The CHW's are "dedicated" mental health workers as opposed to being "generalists" and their activities involve a significant investment of their time due to the specialized nature of the services offered such as counselling, screening and home visits. The CHWs are stretched beyond their standard work hours. Non-value added but necessary activities consumed a significant proportion of their time at the expense of value-added activities. Work flow redesign and implementation of Health Management Information Systems (HMIS) can mitigate inefficiencies.


Assuntos
Serviços de Saúde Comunitária/organização & administração , Agentes Comunitários de Saúde , Serviços de Assistência Domiciliar/organização & administração , Serviços de Saúde Mental/organização & administração , Estudos de Tempo e Movimento , Visita Domiciliar/estatística & dados numéricos , Humanos , Índia , Serviços de Saúde Rural/organização & administração , Fluxo de Trabalho
2.
BMC Public Health ; 19(1): 1415, 2019 Oct 29.
Artigo em Inglês | MEDLINE | ID: mdl-31664981

RESUMO

BACKGROUND: Appropriate contraceptive use remains a major health challenge in rural Jordan. The Japan International Cooperation Agency implemented a project aimed at enhancing the capacity of village health centers (VHCs) to improve the quality and quantity of family planning (FP) services in rural Jordan in 2016-2018. Facility- and community-based approaches were integrated into the interventions. We evaluated the project's impacts on contraceptive behaviors and the effectiveness of the two approaches. METHODS: We used a difference-in-differences analysis based on the project baseline and endline surveys, and logistic regression analysis to assess associations between eight primary outcomes and three secondary outcomes (impacts). The unit of intervention was five target VHCs; the unit of analysis was currently married women of reproductive age (15-49 years) in five intervention and five control villages. RESULTS: Overall, 2061 married women participated; 83.8% were in need of FP. Compared with the control villages, significant effects, ranging from + 0.4% points (pp) to + 11.5 pp., were observed in the intervention villages for six primary outcomes in these categories: increasing the use of FP services at VHCs, participation in health promotion activities, and changing the sources of reproductive health information. There was a trend toward improved secondary outcomes in the intervention villages, but no significant differences were observed between the intervention and control villages regarding modern contraceptive use (mCU; + 4.3 pp), traditional contraceptive use (tCU; - 0.5 pp), and spousal agreement on contraception (+ 5.1 pp). mCU was positively associated with five primary outcomes: obtaining contraceptives at VHCs [adjusted odds ratio (AOR) 3.44, 95% confidence interval (CI) 1.26-9.40], education sessions at VHC (AOR 7.41, 95% CI 1.60-34.39), health activities in communities (AOR 7.41, 95% CI 3.28-16.78), counseling by private doctor/clinic (AOR 0.62, 95% CI 0.40-0.97), and information gained through TV (AOR 0.50, 95% CI 0.32-0.76). Spousal agreement on contraception showed similar positive trends. tCU was associated only with TV. CONCLUSIONS: The project had impacts on increased mCU and husbands' perception of contraception in rural Jordan. The integration of facility- and community-based approaches may be effective in shifting from tCU to mCU in other rural areas.


Assuntos
Comportamento Contraceptivo/estatística & dados numéricos , Serviços de Planejamento Familiar/organização & administração , Serviços de Saúde Rural/organização & administração , População Rural , Adolescente , Adulto , Feminino , Pesquisa sobre Serviços de Saúde , Humanos , Jordânia , Estado Civil/estatística & dados numéricos , Pessoa de Meia-Idade , População Rural/estatística & dados numéricos , Adulto Jovem
3.
BMC Health Serv Res ; 19(1): 758, 2019 Oct 26.
Artigo em Inglês | MEDLINE | ID: mdl-31655576

RESUMO

BACKGROUND: Despite a national focus on closing the gap between Aboriginal and non-Aboriginal child health outcomes in Australia, there remain significant challenges, including provision of health services in very remote communities. We aimed to identify and map child health services in the very remote Fitzroy Valley, West Kimberley, and document barriers to effective service delivery. METHODS: Identification and review of all regional child health services and staffing in 2013. Verification of data by interview with senior managers and staff of key providers in the Western Australian Country Health Service, Kimberley Population Health Unit, Nindilingarri Cultural Health Services and non-government providers. RESULTS: We identified no document providing a comprehensive overview of child health services in the Fitzroy Valley. There were inadequate numbers of health professionals, facilities and accommodation; high staff turnover; and limited capacity and experience of local health professionals. Funding and administrative arrangements were complex and services poorly coordinated and sometimes duplicated. The large geographic area, distances, extreme climate and lack of public and private transport challenge service delivery. The need to attend to acute illness acts to deprioritise crucial primary and preventative health care and capacity for dealing with chronic, complex disorders. Some services lack cultural safety and there is a critical shortage of Aboriginal Health Workers (AHW). CONCLUSIONS: Services are fragmented and variable and would benefit from a coordinated approach between government, community-controlled agencies, health and education sectors. A unifying model of care with emphasis on capacity-building in Aboriginal community members and training and support for AHW and other health professionals is required but must be developed in consultation with communities. Innovative diagnostic and care models are needed to address these challenges, which are applicable to many remote Australian settings outside the Fitzroy Valley, as well as other countries globally. Our results will inform future health service planning and strategies to attract and retain health professionals to work in these demanding settings. A prospective audit of child health services is now needed to inform improved planning of child health services with a focus on identifying service gaps and training needs and better coordinating existing services to improve efficiency and potentially also efficacy.


Assuntos
Serviços de Saúde da Criança/organização & administração , Serviços de Saúde do Indígena/organização & administração , Serviços de Saúde Rural/organização & administração , Criança , Pesquisa sobre Serviços de Saúde , Humanos , Austrália Ocidental
4.
BMC Health Serv Res ; 19(1): 756, 2019 Oct 26.
Artigo em Inglês | MEDLINE | ID: mdl-31655588

RESUMO

BACKGROUND: Village Health and Nutrition Days (VHNDs) are a cornerstone of the Government of India's strategy to provide first-contact primary health care to rural areas. Recent government programmes such as the Janani Suraksha Yojana (JSY) and Mission Indradhanush (MI) have catalysed important changes impacting VHNDs. To learn how VHNDs are currently being delivered, we assessed the fidelity of services provided as compared to government norms in a priority district of Uttar Pradesh. METHODS: We fielded a cross-sectional study of VHNDs to provide a snapshot of health services functioning. Process evaluation data were collected via administrative sources, non-participant observation using a standardised form, and structured questionnaires. Questionnaires were designed using a framework to assess implementation fidelity. Key respondents were VHND participants, front-line workers involved in VHND delivery, and VHND non-participants (pregnant women due for antenatal care or children due for vaccination as per administrative records). Results were summarised as counts, frequencies, and proportions. RESULTS: In the 30 villages randomly selected for inclusion, 36 VHNDs were scheduled but four (11.1%) were cancelled and one VHND was not surveyed. Vaccination and antenatal care were offered at 96.8% (30/31) and child weighing at 83.9% (26/31) of VHNDs. Other normed services were infrequently provided or completely absent. Health education and promotion were particularly weak; institutional delivery was the only topic discussed in a majority of VHNDs. The true proportion of any serious problem impeding vaccine delivery was 47.2% (17/36), comprising 4 VHND cancellations and 13 VHNDs experiencing vaccine shortages. Of the 13 incidents of vaccine shortage, 11 related to an unexpected global shortage of injectable polio vaccine (IPV). Over the 31 VHNDs, 37.8% (171 of the 452 scheduled beneficiaries) did not participate. Analysis of missed opportunities for vaccination highlighted inaccuracies in beneficiary identification and tracking and demand side-factors. CONCLUSIONS: The transformative potential of VHNDs to improve population health is only partially being met. A core subset of high-priority services for antenatal care, institutional delivery, and vaccination associated with high-priority government programmes (JSY, MI) is now being provided quite successfully. Other basic health promotion and prevention services are largely not provided, constituting a critical missed opportunity.


Assuntos
Transtornos da Nutrição Infantil/prevenção & controle , Serviços de Saúde Materno-Infantil/organização & administração , Serviços de Saúde Rural/organização & administração , Saúde da População Rural/estatística & dados numéricos , Adulto , Criança , Transtornos da Nutrição Infantil/epidemiologia , Estudos Transversais , Feminino , Pesquisa sobre Serviços de Saúde , Humanos , Índia/epidemiologia , Masculino , Gravidez , Cuidado Pré-Natal/organização & administração , Inquéritos e Questionários , Vacinação
5.
Rev Infirm ; 68(254): 33-35, 2019 Oct.
Artigo em Francês | MEDLINE | ID: mdl-31587850

RESUMO

Many rural areas, far from hospitals, are seeing a decline in the number of general practitioners, making it more difficult for patients in these regions to access care. However, there are relevant solutions, as illustrated by the Dousopal network in Normandy, which, teaming up with home care providers, contributes to organising palliative care support for all, in optimal conditions.


Assuntos
Cuidados Paliativos/organização & administração , Serviços de Saúde Rural/organização & administração , França , Clínicos Gerais/provisão & distribução , Acesso aos Serviços de Saúde , Serviços de Assistência Domiciliar/organização & administração , Humanos
6.
PLoS Med ; 16(10): e1002939, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31647821

RESUMO

BACKGROUND: The coverage of community-based maternal, neonatal, and child health (MNCH) services remains low, especially in hard-to-reach areas. We evaluated the effectiveness of a mobile-phone-and web-based application, Innovative Mobile-phone Technology for Community Health Operations (ImTeCHO), as a job aid to the government's Accredited Social Health Activists (ASHAs) and Primary Health Center (PHC) staff to improve coverage of MNCH services in rural tribal communities of Gujarat, India. METHODS AND FINDINGS: This open cluster-randomized trial was conducted in 22 PHCs in six tribal blocks of Bharuch and Narmada districts in India. The ImTeCHO mobile-phone-and web-based application included various technology-based job aids to facilitate scheduling of home visits, screening for complications, counseling during home visits, and supportive supervision by PHC staff. Primary outcome indicators were a composite index calculated based on coverage of important MNCH services and coverage of at least two home visitations by ASHA within the first week of birth. Primary analysis was intention to treat (ITT). Generalized Estimating Equation (GEE) was used to account for clustering. Eleven PHCs each were randomly allocated to the intervention (280 ASHAs, population: 234,134) and control (281 ASHAs, population: 242,809) arms. The intervention was implemented from February, 2016 to January, 2017. At the end of the implementation, 6,493 mothers were surveyed. Most of the surveyed women were tribal (5,571, 85.8%), and reported having a government-issued certificate for living below poverty line (4,916, 75.7%). The coverage of at least two home visits within first week of birth was 32.4% in the intervention clusters compared to 22.9% in the control clusters (adjusted effect size 10.2 [95% CI: 6.4, 14.0], p < 0.001). Mean number of home visits within first week of birth was 1.11 and 0.80 for intervention and control clusters, respectively (adjusted effect size 0.34 [95% CI: 0.23, 0.45], p < 0.001). The composite coverage index was 43.0% in the intervention clusters compared to 38.5% (adjusted effect size 4.9 [95% CI: 0.2, 9.5], p = 0.03) in the control clusters. There were substantial improvements in coverage home visits by ASHAs during antenatal period (adjusted effect size 15.7 [95% CI: 11.0, 20.4], p < 0.001), postnatal period (adjusted effect size 6.4, [95% CI: 3.2, 9.6], p <0.001), early initiation of breastfeeding (adjusted effect size 7.8 [95% CI: 4.2, 11.4], p < 0.001), and exclusive breastfeeding (adjusted effect size 13.4 [95% CI: 8.9, 17.9], p < 0.001). Number of infant and neonatal deaths was similar in the two arms in the ITT analysis. The limitations of the study include potential risk of inaccuracies in reporting events that occurred during pregnancy by the mothers and the duration of intervention being 12 months, which might be considered short. CONCLUSIONS: In this study, we found that use of ImTeCHO mobile- and web-based application as a job aid by government ASHAs and PHC staff improved coverage and quality of MNCH services in hard-to-reach areas. Supportive supervision, change management, and timely resolution of technology-related issues were critical implementation considerations to ensure adherence to the intervention. TRIAL REGISTRATION: Study was registered at the Clinical Trial Registry of India (www.ctri.nic.in). Trial number: CTRI/2015/06/005847. The trial was registered (prospective) on 3 June, 2015. First enrollment was done on 26 August, 2015.


Assuntos
Serviços de Saúde da Criança/organização & administração , Serviços de Saúde Materna/organização & administração , Neonatologia/organização & administração , Telemedicina/métodos , Adulto , Telefone Celular , Análise por Conglomerados , Agentes Comunitários de Saúde , Aconselhamento , Feminino , Serviços de Assistência Domiciliar , Visita Domiciliar , Humanos , Índia/epidemiologia , Recém-Nascido , Internet , Masculino , Gravidez , Desenvolvimento de Programas , Serviços de Saúde Rural/organização & administração , População Rural , Resultado do Tratamento , Adulto Jovem
7.
BMC Health Serv Res ; 19(1): 709, 2019 Oct 17.
Artigo em Inglês | MEDLINE | ID: mdl-31623609

RESUMO

BACKGROUND: With rural population aging there are growing numbers of people with dementia in rural and remote settings. The role of primary health care (PHC) is critical in rural locations, yet there is a lack of rural-specific PHC models for dementia, and little is known about factors influencing the development, implementation, and sustainability of rural PHC interventions. Using a community-based participatory research approach, researchers collaborated with a rural PHC team to co-design and implement an evidence-based interdisciplinary rural PHC memory clinic in the Canadian province of Saskatchewan. This paper reports barriers and facilitators to developing, implementing, and sustaining the intervention. METHODS: A qualitative longitudinal process evaluation was conducted over two and half years, from pre- to post-implementation. Data collection and analyses were guided by the Consolidated Framework for Implementation Research (CFIR) which consists of 38 constructs within five domains: innovation characteristics, outer setting, inner setting, individual characteristics, and process. Data were collected via focus groups with the PHC team and stakeholders, smaller team workgroup meetings, and team member interviews. Analysis was conducted using a deductive approach to apply CFIR codes to the data and an inductive analysis to identify barriers and facilitators. RESULTS: Across all domains, 14 constructs influenced development and implementation. Three domains (innovation characteristics, inner setting, process) were most important. Facilitators were the relative advantage of the intervention, ability to trial on a small scale, tension for change, leadership engagement, availability of resources, education and support from researchers, increased self-efficacy, and engagement of champions. Barriers included the complexity of multiple intervention components, required practice changes, lack of formal incentive programs, time intensiveness of modifying the EMR during iterative development, lack of EMR access by all team members, lack of co-location of team members, workload and busy clinical schedules, inability to justify a designated dementia care manager role, and turnover of PHC team members. CONCLUSIONS: The study identified key factors that supported and hindered the development and implementation of a rural-specific strategy for dementia assessment and management in PHC. Despite challenges related to the rural context, the researcher-academic partnership was successful in developing and implementing the intervention.


Assuntos
Demência/terapia , Acesso aos Serviços de Saúde , Atenção Primária à Saúde/organização & administração , Serviços de Saúde Rural/organização & administração , Feminino , Grupos Focais , Humanos , Estudos Longitudinais , Masculino , Pesquisa Qualitativa , Saskatchewan
8.
BMC Health Serv Res ; 19(1): 675, 2019 Sep 18.
Artigo em Inglês | MEDLINE | ID: mdl-31533696

RESUMO

BACKGROUND: The Ghana Community-based Health Planning and Services (CHPS) initiative is a national strategy for improving access to primary health care services for underserved communities. Following a successful trial in the North Eastern part of the country, CHPS was adopted as Ghana's flagship programme for achieving the Universal Health Coverage. Recent empirical evidence suggests, however, that scale-up of CHPS has not necessarily replicated the successes of the pilot study. This study examines the community's perspective of the performance of CHPS and how the scale up could potentially align with the original experimental study. METHOD: Applying a qualitative research methodology, this study analysed transcripts from 20 focus group discussions (FGDs) in four functional CHPS zones in separate districts of the Northern and Volta Regions of Ghana to understand the community's assessment of CHPS. The study employed the thematic analysis to explore the content of the CHPS service provision, delivery and how community members feel about the service. In addition, ordinary least regression model was applied in interpreting 126 scores consigned to CHPS by the study respondents. RESULTS: Two broad areas of consensus were observed: general favourable and general unfavourable thematic areas. Favourable themes were informed by approval, appreciation, hard work and recognition of excellent services. The unfavourable thematic area was informed by rudeness, extortion, inappropriate and unprofessional behaviour, lack of basic equipment and disappointments. The findings show that mothers of children under the age of five, adolescent girls without children, and community leaders generally expressed favourable perceptions of CHPS while fathers of children under the age of five and adolescent boys without children had unfavourable expressions about the CHPS program. A narrow focus on maternal and child health explains the demographic divide on the perception of CHPS. The study revealed wide disparities in actual CHPS deliverables and community expectations. CONCLUSIONS: A communication gap between health care providers and community members explains the high and unrealistic expectations of CHPS. Efforts to improve program acceptability and impact should address the need for more general outreach to social networks and men rather than a sole focus on facility-based maternal and child health care.


Assuntos
Atenção Primária à Saúde/organização & administração , Serviços de Saúde Rural/organização & administração , Adolescente , Adulto , Criança , Pai/estatística & dados numéricos , Feminino , Gana , Pessoal de Saúde , Humanos , Masculino , Mães/estatística & dados numéricos , Projetos Piloto , Cobertura Universal do Seguro de Saúde/organização & administração
9.
BMC Health Serv Res ; 19(1): 649, 2019 Sep 09.
Artigo em Inglês | MEDLINE | ID: mdl-31500612

RESUMO

BACKGROUND: Fetal alcohol spectrum disorder (FASD) is a highly prevalent neurodevelopmental disorder associated with prenatal alcohol exposure. Early identification can improve functioning for individuals and reduce costs to society. Gold standard methods of diagnosing FASD rely on specialists to deliver intensive, multidisciplinary assessments. While comprehensive, prevalence rates highlight that this assessment model cannot meet demand, nor is it feasible in remote areas where specialist services are lacking. This project aims to expand the capabilities of remote practitioners in north Queensland, Australia, where 23-94% of the community identify as First Nations people. Integrating cultural protocols with the implementation science theories of Knowledge-To-Action, Experience-Based Co-Design, and RE-AIM, remote practitioners with varying levels of experience will be trained in a co-designed, culturally appropriate, tiered neurodevelopmental assessment process that considers FASD as a potential outcome. This innovative assessment process can be shared between primary and tertiary health care settings, improving access to services for children and families. This project aims to demonstrate that neurodevelopmental assessments can be integrated seamlessly with established community practices and sustained through evidence-based workforce development strategies. METHODS: The Yapatjarrathati project (named by the local First Nations community and meaning 'to get well') is a mixed-method implementation trial of a tiered assessment process for identifying FASD within a remote Australian community. In collaboration with the community, we co-designed: (a) a culturally sensitive, tiered, neurodevelopmental assessment process for identifying FASD, and (b) training materials that up-skill remote practitioners with varying levels of expertise. Qualitative interviews for primary, secondary and end users will be undertaken to evaluate the implementation strategies. RE-AIM will be used to evaluate the reach, effectiveness, adoption, implementation and maintenance of the assessment and training process. DISCUSSION: Co-designed with the local community, integrated with cultural protocols, and based on implementation science theories, the assessment and training process from this project will have the potential to be scaled-up across other remote locations and trialed in urban settings. The Yapatjarrathati project is an important step towards increasing the availability of neurodevelopmental services across Australia and empowering remote practitioners to contribute to the FASD assessment process.


Assuntos
Transtornos do Espectro Alcoólico Fetal/prevenção & controle , Serviços de Saúde do Indígena/organização & administração , Serviços de Saúde Rural/organização & administração , Competência Cultural , Estudos de Avaliação como Assunto , Feminino , Transtornos do Espectro Alcoólico Fetal/epidemiologia , Conhecimentos, Atitudes e Prática em Saúde , Promoção da Saúde/organização & administração , Humanos , Recém-Nascido , Gravidez , Queensland/epidemiologia , População Rural
10.
Trials ; 20(1): 496, 2019 Aug 13.
Artigo em Inglês | MEDLINE | ID: mdl-31409421

RESUMO

BACKGROUND: HIV-testing coverage remains below the targeted 90% despite efforts and resources invested. Home-based HIV-testing is a key approach endorsed by the World Health Organization (WHO), especially to reach individuals who might not seek testing otherwise. Although acceptance of testing during such campaigns is high, coverage remains low due to absent household members. This cluster-randomized trial aims to assess increase in testing coverage using oral HIV self-testing (HIVST) among individuals who are absent or decline testing during home-based HIV-testing. METHODS: The HOSENG (HOme-based SElf-testiNG) trial is a cluster-randomized, parallel-group, superiority trial in two districts of Lesotho, Southern Africa. Clusters are stratified by district, village size, and village access to the nearest health facility. Cluster eligibility criteria include: village is in catchment area of one of the study facilities, village authority provides consent, and village has a registered, capable, and consenting village health worker (VHW). In intervention clusters, HIV self-tests are provided for eligible household members who are absent or decline HIV-testing in the presence of the campaign team. In control clusters, standard of care for absent and refusing individuals applies, i.e., referral to a health facility. The primary outcome is HIV-testing coverage among individuals aged 12 years or older within 120 days after enrollment. Secondary objectives include HIV-testing coverage among other age groups, and uptake of the different testing modalities. Statistical analyses will be conducted and reported in line with CONSORT guidelines. The HOSENG trial is linked to the VIBRA (Village-Based Refill of ART) trial. Together, they constitute the GET ON (GETting tOwards Ninety) research project. DISCUSSION: The HOSENG trial tests whether oral HIVST may be an add-on during door-to-door testing campaigns towards achieving optimal testing coverage. The provision of oral self-test kits, followed up by VHWs, requires little additional human resources, finances and logistics. If cost-effective, this approach should inform home-based HIV-testing policies not only in Lesotho, but in similar high-prevalence settings. TRIAL REGISTRATION: ClinicalTrials.gov, (ID: NCT03598686 ). Registered on 25 July 2018. More information is available at www.getonproject.wordpress.com .


Assuntos
Agentes Comunitários de Saúde/organização & administração , Infecções por HIV/diagnóstico , Promoção da Saúde/organização & administração , Visita Domiciliar , Programas de Rastreamento/organização & administração , Aceitação pelo Paciente de Cuidados de Saúde , Serviços de Saúde Rural/organização & administração , Autocuidado , Adolescente , Adulto , Criança , Estudos de Equivalência como Asunto , Feminino , Infecções por HIV/terapia , Humanos , Lesoto , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Fatores de Tempo , Adulto Jovem
11.
Artigo em Inglês | MEDLINE | ID: mdl-31430889

RESUMO

Integrated healthcare has received considerable attention and has developed into the highly important health policy known as Integrated Healthcare in County (IHC) against the background of the Grading Diagnosis and Treatment System (GDTS) in rural China. However, the causal conditions under which different integrated health-care modes might be selected are poorly understood, particularly in the context of China's authoritarian regime. This study aims to identify these causal conditions, and how they shape the mode selection mechanism for Integrated Healthcare in County (IHC). A theoretical framework consisting of resource heterogeneity, governance structure, and institutional normalization was proposed, and a sample of fifteen IHCs was selected, with data for each IHC being collected from news reports, work reports, government documents and field research for Fuzzy-sets Qualitative Comparative Analysis (fsQCA). This study firstly pointed out that strong governmental control and centralization are necessary conditions for the administration-oriented organization mode (MOA). Additionally, this research found three critical configured paths in the selection of organizational modes. Specifically, we found that the combination of low resource heterogeneity, weak governmental control, centralization, and normalization was sufficient to explain the selection path of the insurance-driven organization mode (MOI); the combination of low resource heterogeneity, strong governmental control, centralization, and normalization was sufficient for selecting MOA; and the combination of weak governmental control, weak centralization, and weak normalization was sufficient for selecting the contractual organization mode (MOC). Our study highlighted the necessity and feasibility of constructing different IHC modes separately and promoting their development gradually, as a result of the complex relationships among the causal conditions described above, thus helping to optimize the distribution of health resources and integrate the healthcare system.


Assuntos
Prestação Integrada de Cuidados de Saúde/organização & administração , Serviços de Saúde Rural/organização & administração , China , Governo , Administração de Instituições de Saúde , Política de Saúde , Recursos em Saúde/organização & administração , Humanos , Modelos Organizacionais
12.
Trials ; 20(1): 522, 2019 Aug 22.
Artigo em Inglês | MEDLINE | ID: mdl-31439004

RESUMO

BACKGROUND: There is a need for evaluating community-based antiretroviral therapy (ART) delivery models to improve overall performance of HIV programs, specifically in populations that may have difficulties to access continuous care. This cluster-randomized clinical trial aims to evaluate the effectiveness of a multicomponent differentiated ART delivery model (VIBRA model) after home-based same-day ART initiation in remote villages in Lesotho, southern Africa. METHODS/DESIGN: The VIBRA trial (VIllage-Based Refill of ART) is a cluster-randomized parallel-group superiority clinical trial conducted in two districts in Lesotho, southern Africa. Clusters (i.e., villages) are randomly assigned to either the VIBRA model or standard care. The clusters are stratified by district, village size, and village access to the nearest health facility. Eligible individuals (HIV-positive, aged 10 years or older, and not taking ART) identified during community-based HIV testing campaigns are offered same-day home-based ART initiation. The intervention clusters offer a differentiated ART delivery package with two features: (1) drug refills and follow-ups by trained and supervised village health workers (VHWs) and (2) the option of receiving individually tailored adherence reminders and notifications of viral load results via SMS. The control clusters will continue to receive standard care, i.e., collecting ART refills from a clinic and no SMS notifications. The primary endpoint is viral suppression 12 months after enrolment. Secondary endpoints include linkage to and engagement in care. Furthermore, safety and cost-effectiveness analyses plus qualitative research are planned. The minimum target sample size is 262 participants. The statistical analyses will follow the CONSORT guidelines. The VIBRA trial is linked to another trial, the HOSENG (HOme-based SElf-testiNG) trial, both of which are within the GET ON (GETing tOwards Ninety) research project. DISCUSSION: The VIBRA trial is among the first to evaluate the delivery of ART by VHWs immediately after ART initiation. It assesses the entire HIV care cascade from testing to viral suppression. As most countries in sub-Saharan Africa have cadres like the VHW program in Lesotho, this model-if shown to be effective-has the potential to be scaled up. The system impact evaluation will provide valuable cost estimations, and the qualitative research will suggest how the model could be further modified to optimize its impact. TRIAL REGISTRATION: Clinicaltrials.gov, NCT03630549 . Registered on 15 August 2018.


Assuntos
Fármacos Anti-HIV/uso terapêutico , Assistência à Saúde/organização & administração , Infecções por HIV/tratamento farmacológico , HIV/efeitos dos fármacos , Adesão à Medicação , Serviços de Saúde Rural/organização & administração , Fármacos Anti-HIV/efeitos adversos , Prescrições de Medicamentos , Estudos de Equivalência como Asunto , HIV/crescimento & desenvolvimento , Infecções por HIV/diagnóstico , Infecções por HIV/virologia , Humanos , Lesoto , Estudos Multicêntricos como Assunto , Fatores de Tempo , Resultado do Tratamento , Carga Viral
13.
Am J Health Syst Pharm ; 76(2): 108-113, 2019 Jan 16.
Artigo em Inglês | MEDLINE | ID: mdl-31408091

RESUMO

PURPOSE: The stages of development of a health system-wide antimicrobial stewardship program (ASP) using existing personnel and technology are described. SUMMARY: Small hospitals with limited resources may struggle to meet ASP requirements, particularly facilities without onsite infectious disease physicians and/or experienced infectious disease pharmacists. Strategies for ASP development employed by Avera Health, a 33-hospital health system in the Midwest, included identifying relevant drug utilization and resistance patterns, education and pathway development, and implementation of Web-based conferencing to provide pharmacists throughout the system with access to infectious disease expertise on a daily basis. These efforts resulted in an evolving single-system ASP that has leveraged existing resources to overcome some system barriers. Program outcomes to date include a reduction in the use of a targeted agent, improved pathogen susceptibility trends, and rates of hospital-associated Clostridium difficile infection below national benchmarks. CONCLUSION: The Avera Health ASP grew from a collaborative project targeting levofloxacin overuse and resistance among key bacteria to a formal, health system-wide ASP in a rural setting. This program used existing personnel to provide standardized processes, educational campaigns, and antimicrobial expertise through the use of technology. This ASP program may provide helpful examples of ASP strategies for other rural health systems with similar resources.


Assuntos
Antibacterianos/uso terapêutico , Gestão de Antimicrobianos/organização & administração , Infecções por Clostridium/tratamento farmacológico , Hospitais Rurais/organização & administração , Desenvolvimento de Programas , Antibacterianos/farmacologia , Gestão de Antimicrobianos/economia , Infecções por Clostridium/microbiologia , Clostridium difficile/efeitos dos fármacos , Clostridium difficile/isolamento & purificação , Clostridium difficile/fisiologia , Farmacorresistência Bacteriana/efeitos dos fármacos , Uso de Medicamentos , Hospitais Rurais/economia , Humanos , Levofloxacino/farmacologia , Levofloxacino/uso terapêutico , Testes de Sensibilidade Microbiana , Farmacêuticos/organização & administração , Serviço de Farmácia Hospitalar/economia , Serviço de Farmácia Hospitalar/organização & administração , Papel Profissional , Avaliação de Programas e Projetos de Saúde , Serviços de Saúde Rural/economia , Serviços de Saúde Rural/organização & administração
14.
Int J Equity Health ; 18(1): 119, 2019 07 30.
Artigo em Inglês | MEDLINE | ID: mdl-31362732

RESUMO

OBJECTIVES: Considerable evidence has advanced the role of citizen-led coalitions (CLC) in supporting the health and social needs of rural citizens. There has been little research focusing on the experiences and strategies of coalitions, with their limited resources and status, in targeting health inequities in their rural communities. The aim of this study was to understand the entrepreneurial strategies and experiences of rural coalitions to effect change in the delivery of health services for their older adult populations. METHOD: A qualitative descriptive study method was used to generate understanding of the entrepreneurial experiences and strategies of CLCs in advancing health services to meet the health and social needs of their citizens. Seven diverse CLCs (n = 40) from different rural communities participated in focus groups and in individual and coalition-level surveys. Thematic analysis was used to construct themes from the data. RESULTS: Two over-riding themes emerged: entrepreneurial strategies and societal recognition. CLCs engaged in numerous entrepreneurial strategies that enabled actions and outcomes in meeting their health care needs. These strategies included: securing quick wins, leveraging existing resources, and joining forces with stakeholder groups/individuals. However, despite these strategies and successes, coalitions expressed frustration with not being seen and not being heard by decision-makers. This pointed to a key structural barrier to coalition successes -- a broader societal and institutional problem of failing to recognize not only the health needs of rural citizens, but also the legitimacy of the community coalitions to represent and act on those needs. CONCLUSIONS: Despite the potential for coalitions to mobilize and effect change in addressing the inequities of rural health service access for older adults, broader barriers to their recognition, may undermine their entrepreneurial strategies and success.


Assuntos
Redes Comunitárias/organização & administração , Acesso aos Serviços de Saúde/organização & administração , Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde/estatística & dados numéricos , Serviços de Saúde Rural/organização & administração , População Rural/estatística & dados numéricos , Idoso , Feminino , Grupos Focais , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Humanos , Masculino , Saúde das Minorias , Inquéritos e Questionários
15.
Pan Afr Med J ; 33: 50, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31448013

RESUMO

Introduction: The World Health Organization estimates that up to half of vaccines are wasted, however only a minority of mHealth programs in Africa have been directed at vaccine supply chain optimisation. We piloted a novel mHealth solution dependent only on short message services (SMS) technology that allowed workers in rural health centres in Zambia to report vaccine stock levels directly to an online platform. Small airtime incentives were offered to encourage users to engage with the system, as well as weekly reminder messages asking for stock updates. Methods: The primary outcome measured was the percentage-of-doses-tracked, calculated over the study period. Each vaccine box was randomly allocated to offer either a standard or double airtime incentive and either weekly or daily reminders, in a 2 x 2 design; ANOVA was used to calculate if any of these factors affected time-to-reply. Results: Over the study period, the total percentage-of-doses-tracked was 39.9%. Within the subset of users who sent at least one message to the platform, the percentage-of-doses-tracked was 93.8%. There was no significant difference in average time-to-reply between the standard airtime incentive and double airtime incentive groups, nor was there a significant difference between the standard reminder and daily follow-up reminder groups. Conclusion: This pilot study found that in an active subgroup of health workers, an incentivised mHealth solution was able to collect tracking data for 93.8% of doses. More research is needed to identify methods to encourage healthcare workers to engage in timely stock reporting practices.


Assuntos
Vacina contra Difteria, Tétano e Coqueluche/provisão & distribução , Serviços de Saúde Rural/organização & administração , Telemedicina/métodos , Mensagem de Texto , Telefone Celular , Agentes Comunitários de Saúde/organização & administração , Humanos , Projetos Piloto , Fatores de Tempo , Zâmbia
18.
Am J Health Syst Pharm ; 76(6): 387-397, 2019 02 21.
Artigo em Inglês | MEDLINE | ID: mdl-31415684

RESUMO

PURPOSE: As a preliminary evaluation of the outcomes of implementing pharmacogenetic testing within a large rural healthcare system, patients who received pre-emptive pharmacogenetic testing and warfarin dosing were monitored until June 2017. SUMMARY: Over a 20-month period, 749 patients were genotyped for VKORC1 and CYP2C9 as part of the electronic Medical Records and Genomics Pharmacogenetics (eMERGE PGx) study. Of these, 27 were prescribed warfarin and received an alert for pharmacogenetic testing pertinent to warfarin; 20 patients achieved their target international normalized ratio (INR) of 2.0-3.0, and 65% of these patients achieved target dosing within the recommended pharmacogenetic alert dose (± 0.5 mg/day). Of these, 10 patients had never been on warfarin prior to the alert and were further evaluated with regard to time to first stable target INR, bleeds and thromboembolic events, hospitalizations, and mortality. There was a general trend of faster time to first stable target INR when the patient was initiated at a warfarin dose within the alert recommendation versus a dose outside of the alert recommendation with a mean (± SD) of 34 (± 28) days versus 129 (± 117) days, respectively. No trends regarding bleeds, thromboembolic events, hospitalization, or mortality were identified with respect to the pharmacogenetic alert. The pharmacogenetic alert provided pharmacogenetic dosing information to prescribing clinicians and appeared to deploy appropriately with the correct recommendation based upon patient genotype. CONCLUSION: Implementing pharmacogenetic testing as a standard of care service in anticoagulation monitoring programs may improve dosage regimens for patients on anticoagulation therapy.


Assuntos
Anticoagulantes/administração & dosagem , Monitoramento de Medicamentos/métodos , Testes Farmacogenômicos , Serviços de Saúde Rural/organização & administração , Varfarina/administração & dosagem , Idoso , Anticoagulantes/efeitos adversos , Fibrilação Atrial/tratamento farmacológico , Coagulação Sanguínea/efeitos dos fármacos , Relação Dose-Resposta a Droga , Feminino , Genótipo , Implementação de Plano de Saúde , Hemorragia/sangue , Hemorragia/induzido quimicamente , Humanos , Coeficiente Internacional Normatizado , Masculino , Pessoa de Meia-Idade , Variantes Farmacogenômicos , Avaliação de Programas e Projetos de Saúde , Estudos Retrospectivos , Padrão de Cuidado , Tromboembolia/sangue , Tromboembolia/prevenção & controle , Varfarina/efeitos adversos
19.
Medicine (Baltimore) ; 98(32): e16693, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31393371

RESUMO

To strengthen rural health services, the Chinese government has launched a series of policies to promote health workforce development. This study aims to understand the current status of village doctors and to explore the factors associated with village doctors' job satisfaction in western China. It also attempts to provide references for further building capacities of village doctors and promoting the development of rural health service policy.A multistage stratified sampling method was used to obtain data from a cross-sectional survey on village doctors across 2 provinces of western China during 2012 to 2013. Quantitative data were collected from village doctors face-to-face, through a self-administered questionnaire.Among the 370 respondents, 225 (60.8%) aged 25 to 44 years, and 268 (72.4%) were covered by health insurance. Their income and working time calculated by workloads were higher than their self-report results. Being healthy, working fewer years, and having government funding and facilities were the positive factors toward their job satisfaction. Village doctors working with government-funded village clinics or facilities were more likely to feel satisfied.Problems identified previously such as low income and lack of insurance, heavy workload and aging were not detected in our study. Instead, village doctors were better-paid and better-covered by social insurance than other local rural residents, with increased job satisfaction. Government policies should pay more attention to improving the quality of rural health services and the income and security system of village doctors, to maintain and increase their job satisfaction and work enthusiasm. Further experimental study could evaluate effects of government input to improve rural health human resources and system development.


Assuntos
Satisfação no Emprego , Médicos/psicologia , Serviços de Saúde Rural/organização & administração , Adulto , Atitude do Pessoal de Saúde , Fortalecimento Institucional , China , Estudos Transversais , Humanos , Serviços de Saúde Rural/legislação & jurisprudência , Autorrelato
20.
S D Med ; 72(6): 267-271, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31461232

RESUMO

INTRODUCTION: Due to an increase in the incidence of skin cancer and a shortage of primary care and specialty physicians in rural areas, creative public health strategies must be employed to address disparities in skin cancer education, prevention, and detection. METHODS: Hair salons in eastern South Dakota communities with populations less than 15,000 were visited in-person by medical student facilitators. Hair professionals at these locations completed pre-survey assessments for baseline self-assessed comfort with detecting suspicious skin lesions and with educating patrons on skin cancer prevention strategies. Their likelihood to both alert patrons of suspicious skin lesions and encourage them to have their lesion evaluated by a physician was also assessed. A 20-minute educational PowerPoint presentation was given. Final assessment was evaluated with a post-presentation survey. RESULTS: Self-assessed hair professional comfort with identifying suspicious skin lesions was higher in post-survey results, in addition, the educational presentation increased comfort with sharing skin cancer prevention information with patrons. Hair professionals also reported increased likelihood that they would alert patrons to suspect skin lesions. Also, hair professionals reported increased likelihood that they would encourage patrons to seek medical care for their concerning lesions. CONCLUSIONS: Hair professionals may act as lay skin cancer educators in rural salons. Educational programs for hair professionals can increase their comfort with detecting lesions suspicious for skin cancer, increase their comfort with sharing skin protection information with patrons, and increase their likelihood of both alerting their patrons about suspicious skin lesions and encouraging their patrons to have their suspicious lesions evaluated.


Assuntos
Educação em Saúde/organização & administração , Serviços de Saúde Rural/organização & administração , Neoplasias Cutâneas , Educação em Saúde/métodos , Humanos , Pele , Neoplasias Cutâneas/prevenção & controle , South Dakota , Inquéritos e Questionários
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA