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1.
J Glob Health ; 11: 04030, 2021 May 22.
Artigo em Inglês | MEDLINE | ID: mdl-34055327

RESUMO

Background: The Strategy of the Integrated Management of Childhood Illness (IMCI) was introduced in Central Asia and Europe to address the absence of evidence-based guidelines, the misuse of antibiotics, polypharmacy and over-hospitalization of children. A study carried out in 16 countries analysed the status and strengths of as well as the barriers to IMCI implementation and investigated how different health systems affect the problems IMCI aims to address. Here we present findings in relation to IMCI's effects on the rational use of drugs, particularly the improved rational use of antibiotics in children, the mechanisms through which these were achieved as well as counteracting system factors. Methods: 220 key informants were interviewed ranging from 5 to 37 per country (median 12). Data was analysed for arising themes and peer-reviewed. Results: The implementation of IMCI led to improved prescribing patterns immediately after training of health workers according to key informants. IMCI provides standard treatment guidelines and an algorithmic diagnostic- and treatment-decision-tool for consistent decision-making. Doctors reported feeling empowered by the training to counsel parents and address their expectations and desire for invasive treatments and the use of multiple drugs. Improved prescribing patterns were not sustained over time but counteracted by factors such as: doctors prescribing antibiotics to create additional revenues or other benefits; aggressive marketing by pharmaceutical companies; parents pressuring doctors to prescribe antibiotics; and access to drugs without prescriptions. Conclusions: Future efforts to improve child health outcomes must include: (1) the continued support to improve health worker performance to enable them to adhere to evidence-based treatment guidelines, (2) patient and parent education, (3) improved reimbursement schemes and prescription regulations and their consistent enforcement and (4) the integration of point-of-care tests differentiating between viral and bacterial infection into standards of care. Pre-requisites will be sufficient remuneration of health workers, sound training, improved health literacy among parents, conducive laws and regulations and reimbursement systems with adequate checks and balances to ensure the best possible care.


Assuntos
Antibacterianos/uso terapêutico , Serviços de Saúde da Criança/organização & administração , Prestação Integrada de Cuidados de Saúde/organização & administração , Gerenciamento Clínico , Uso Indevido de Medicamentos/prevenção & controle , Criança , Humanos
2.
PLoS One ; 16(5): e0251382, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33961682

RESUMO

BACKGROUND: The presence of COVID-19 has led to the disruption of health systems globally, including essential reproductive, maternal, newborn and child health (RMNCH) services. This study aimed to assess the challenges faced by women who used RMNCH services in Nigeria's epicentre, their satisfaction with care received during the COVID-19 pandemic and the factors associated with their satisfaction. METHODS: This cross-sectional survey was conducted in Lagos, southwest Nigeria among 1,241 women of reproductive age who had just received RMNCH services at one of twenty-two health facilities across the primary, secondary and tertiary tiers of health care. The respondents were selected via multi-stage sampling and face to face exit interviews were conducted by trained interviewers. Client satisfaction was assessed across four sub-scales: health care delivery, health facility, interpersonal aspects of care and access to services. Bivariate and multivariate analyses were used to assess the relationship between personal characteristics and client satisfaction. RESULTS: About 43.51% of respondents had at least one challenge in accessing RMNCH services since the COVID-19 outbreak. Close to a third (31.91%) could not access service because they could not leave their houses during the lockdown and 18.13% could not access service because there was no transportation. The mean clients' satisfaction score among the respondents was 43.25 (SD: 6.28) out of a possible score of 57. Satisfaction scores for the interpersonal aspects of care were statistically significantly lower in the PHCs and general hospitals compared to teaching hospitals. Being over 30 years of age was significantly associated with an increased clients' satisfaction score (ß = 1.80, 95%CI: 1.10-2.50). CONCLUSION: The COVID-19 lockdown posed challenges to accessing RMNCH services for a significant proportion of women surveyed. Although overall satisfaction with care was fairly high, there is a need to provide tailored COVID-19 sensitive inter-personal care to clients at all levels of care.


Assuntos
Serviços de Saúde da Criança , Serviços de Saúde Materna , Satisfação do Paciente , Serviços de Saúde Reprodutiva , Adolescente , Adulto , /patologia , Estudos Transversais , Feminino , Instalações de Saúde/estatística & dados numéricos , Humanos , Recém-Nascido , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Nigéria/epidemiologia , Pandemias , Satisfação do Paciente/estatística & dados numéricos , Gravidez , Adulto Jovem
3.
Clin Obstet Gynecol ; 64(2): 398-406, 2021 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-33904845

RESUMO

Mobile applications and telehealth services are being used to unprecedented degrees in maternal and child care, with uncertain impact on population health outcomes. In this article, we will review the role of the COVID-19 pandemic in accelerating large scale implementation of telehealth services, known and anticipated impacts on maternal and child health and related inequities, and potential strategies to optimize outcomes at the population level.


Assuntos
Serviços de Saúde da Criança , Saúde da Criança , Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde , Serviços de Saúde Materna , Telemedicina/métodos , /prevenção & controle , Centers for Medicare and Medicaid Services, U.S. , Criança , Serviços de Saúde da Criança/organização & administração , Pré-Escolar , Grupos Étnicos , Feminino , Política de Saúde , Humanos , Lactente , Recém-Nascido , Serviços de Saúde Materna/organização & administração , Grupos Minoritários , Aplicativos Móveis , Avaliação de Resultados em Cuidados de Saúde , Gravidez , Determinantes Sociais da Saúde , Telemedicina/organização & administração , Estados Unidos
4.
BMC Health Serv Res ; 21(1): 354, 2021 Apr 16.
Artigo em Inglês | MEDLINE | ID: mdl-33863326

RESUMO

BACKGROUND: The Integrated eDiagnosis Approach (IeDA), centred on an electronic Clinical Decision Support System (eCDSS) developed in line with national Integrated Management of Childhood Illness (IMCI) guidelines, was implemented in primary health facilities of two regions of Burkina Faso. An evaluation was performed using a stepped-wedge cluster randomised design with the aim of determining whether the IeDA intervention increased Health Care Workers' (HCW) adherence to the IMCI guidelines. METHODS: Ten randomly selected facilities per district were visited at each step by two trained nurses: One observed under-five consultations and the second conducted a repeat consultation. The primary outcomes were: overall adherence to clinical assessment tasks; overall correct classification ignoring the severity of the classifications; and overall correct prescription according to HCWs' classifications. Statistical comparisons between trial arms were performed on cluster/step-level summaries. RESULTS: On average, 54 and 79% of clinical assessment tasks were observed to be completed by HCWs in the control and intervention districts respectively (cluster-level mean difference = 29.9%; P-value = 0.002). The proportion of children for whom the validation nurses and the HCWs recorded the same classifications (ignoring the severity) was 73 and 79% in the control and intervention districts respectively (cluster-level mean difference = 10.1%; P-value = 0.004). The proportion of children who received correct prescriptions in accordance with HCWs' classifications were similar across arms, 78% in the control arm and 77% in the intervention arm (cluster-level mean difference = - 1.1%; P-value = 0.788). CONCLUSION: The IeDA intervention improved substantially HCWs' adherence to IMCI's clinical assessment tasks, leading to some overall increase in correct classifications but to no overall improvement in correct prescriptions. The largest improvements tended to be observed for less common conditions. For more common conditions, HCWs in the control districts performed relatively well, thus limiting the scope to detect an overall impact. TRIAL REGISTRATION: ClinicalTrials.gov NCT02341469 ; First submitted August 272,014, posted January 19, 2015.


Assuntos
Serviços de Saúde da Criança , Prestação Integrada de Cuidados de Saúde , Burkina Faso , Criança , Pessoal de Saúde , Humanos , Encaminhamento e Consulta
6.
BMC Res Notes ; 14(1): 140, 2021 Apr 16.
Artigo em Inglês | MEDLINE | ID: mdl-33863371

RESUMO

OBJECTIVE: The COVID-19 pandemic and the measures implemented to stop the pandemic had a broad impact on our daily lives. Besides work and social life, health care is affected on many levels. In particular, there is concern that attendance in health care programs will drop or hospital admissions will be delayed due to COVID-19-related anxieties, especially in children. Therefore, we compared the number of weekly visits to 78 German pediatric institutions between 2019 and 2020. RESULTS: We found no significant differences during the first 10 weeks of the year. However, and importantly, from April, the weekly number of visits was more than 35% lower in 2020 than in 2019 (p = 0.005). In conclusion, the COVID-19 pandemic seems to relate to families´ utilization of outpatient well-child clinics and pediatric practice attendance in Germany.


Assuntos
Serviços de Saúde da Criança/tendências , Pandemias , Aceitação pelo Paciente de Cuidados de Saúde , Pediatria/tendências , Criança , Alemanha/epidemiologia , Humanos
7.
Soc Sci Med ; 274: 113795, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33667744

RESUMO

BACKGROUND: In the last two decades, India's central and many state governments launched several public health programs with the goal of improving maternal and child health outcomes. Many individual studies assessed the impact of these programs; however, they focused on select health programs and few specific outcomes. OBJECTIVES AND METHODS: This paper summarizes the literature, published during 2000-2019, investigating the impacts of public health programs on both the uptake of maternal and child health services and the related-health outcomes in India. We followed PRISMA guidelines of systematic review, and carried out a narrative synthesis of the study findings. FINDINGS AND CONCLUSION: We found 66 relevant studies covering 11 health programs across India. Most studies had applied non-experimental study designs (n = 50), with few applying experimental (n = 1) and quasi-experimental (n = 15) designs. Most studies (n = 64) assessed the impact on the intermediate outcomes of the uptake of various health services rather on the long-term outcomes of improvement in health. Overall we found studies reporting positive impacts, however, we could not find any strong consensus emerging from these studies about the impact, partly due to differences in: outcome indicators; study designs; study population; data sets. Several studies also reported considerable beneficial impacts among low socioeconomic population groups. However, given that the outreach of the public health programs have been low across the country and population groups, we found that broader objectives of health programs remained unassessed: most studies assessed the impact on who actually participated in the program (average treatment effect on-the-treated) rather on the target population (intent-to-treat effect). Furthermore, there was dearth of research on the impacts of the state-level programs. Future research need to assess the impact of the programs on health outcomes, and on quality adjusted measures of maternal and child health services and its continuum of care.


Assuntos
Serviços de Saúde da Criança , Serviços de Saúde Materna , Criança , Feminino , Promoção da Saúde , Humanos , Índia/epidemiologia , Avaliação de Resultados em Cuidados de Saúde , Gravidez , Saúde Pública
10.
BMJ Glob Health ; 6(3)2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33758014

RESUMO

We have worked to develop a Clinical Information Network (CIN) in Kenya as an early form of learning health systems (LHS) focused on paediatric and neonatal care that now spans 22 hospitals. CIN's aim was to examine important outcomes of hospitalisation at scale, identify and ultimately solve practical problems of service delivery, drive improvements in quality and test interventions. By including multiple routine settings in research, we aimed to promote generalisability of findings and demonstrate potential efficiencies derived from LHS. We illustrate the nature and range of research CIN has supported over the past 7 years as a form of LHS. Clinically, this has largely focused on common, serious paediatric illnesses such as pneumonia, malaria and diarrhoea with dehydration with recent extensions to neonatal illnesses. CIN also enables examination of the quality of care, for example that provided to children with severe malnutrition and the challenges encountered in routine settings in adopting simple technologies (pulse oximetry) and more advanced diagnostics (eg, Xpert MTB/RIF). Although regular feedback to hospitals has been associated with some improvements in quality data continue to highlight system challenges that undermine provision of basic, quality care (eg, poor access to blood glucose testing and routine microbiology). These challenges include those associated with increased mortality risk (eg, delays in blood transfusion). Using the same data the CIN platform has enabled conduct of randomised trials and supports malaria vaccine and most recently COVID-19 surveillance. Employing LHS principles has meant engaging front-line workers, clinical managers and national stakeholders throughout. Our experience suggests LHS can be developed in low and middle-income countries that efficiently enable contextually appropriate research and contribute to strengthening of health services and research systems.


Assuntos
Serviços de Saúde da Criança/normas , Atenção à Saúde/normas , Acesso aos Serviços de Saúde/normas , Pesquisa sobre Serviços de Saúde , Melhoria de Qualidade , /epidemiologia , Criança , Pré-Escolar , Países em Desenvolvimento , Diarreia/epidemiologia , Diarreia/prevenção & controle , Humanos , Lactente , Recém-Nascido , Quênia/epidemiologia , Malária/epidemiologia , Malária/prevenção & controle , Pandemias , Pneumonia/epidemiologia , Pneumonia/prevenção & controle
11.
BMC Health Serv Res ; 21(1): 270, 2021 Mar 24.
Artigo em Inglês | MEDLINE | ID: mdl-33761936

RESUMO

BACKGROUND: Studies focusing on the Integrated Management of Childhood Illness (IMCI) program in the Philippines are limited, and perspectives of frontline health care workers (HCWs) are largely absent in relation to the introduction and current implementation of the program. Here, we describe the operational challenges and opportunities described by HCWs implementing IMCI in five regions of the Philippines. These perspectives can provide insights into how IMCI can be strengthened as the program matures, in the Philippines and beyond. METHODS: In-depth interviews (IDIs) were conducted with HCWs (n = 46) in five provinces (Ilocos Sur, Quezon, National Capital Region, Bohol and Davao), with full transcription and translation as necessary. In parallel, data collectors observed the status (availability and placement) of IMCI-related materials in facilities. All data were coded using NVivo 12 software and arranged along a Social Ecological Model. RESULTS: HCWs spoke of the benefits of IMCI and discussed how they developed workarounds to ensure that integral components of the program could be delivered in frontline facilities. Five key challenges emerged in relation to IMCI implementation in primary health care (PHC) facilities: 1) insufficient financial resources to fund program activities, 2) inadequate training, mentoring and supervision among and for providers, 3) fragmented leadership and governance, 4) substandard access to IMCI relevant written documents, and 5) professional hierarchies that challenge fidelity to IMCI protocols. CONCLUSION: Although the IMCI program was viewed by HCWs as holistic and as providing substantial benefits to the community, more viable implementation processes are needed to bolster acceptability in PHC facilities.


Assuntos
Serviços de Saúde da Criança , Prestação Integrada de Cuidados de Saúde , Criança , Pessoal de Saúde , Humanos , Filipinas
12.
Int J Equity Health ; 20(1): 77, 2021 03 15.
Artigo em Inglês | MEDLINE | ID: mdl-33722225

RESUMO

Global response to COVID-19 pandemic has inadvertently undermined the achievement of existing public health priorities and laregely overlooked local context. Recent evidence suggests that this will cause additional maternal and childhood mortality and morbidity especially in low- and middle-income countries (LMICs). Here we have explored the contextual factors influencing maternal, neonatal and children health (MNCH) care in Bangladesh, Nigeria and South Africa amidst the pandemic. Our findings suggest that between March and May 2020, there was a reduction in utilisation of basic essential MNCH services such as antenatal care, family planning and immunization due to: a) the implementation of lockdown which triggered fear of contracting the COVID-19 and deterred people from accessing basic MNCH care, and b) a shift of focus towards pandemic, causing the detriment to other health services, and c) resource constraints. Taken together these issues have resulted in compromised provision of basic general healthcare. Given the likelihood of recurrent waves of the pandemic globally, COVID-19 mitigation plans therefore should be integrated with standard care provision to enhance system resilience to cope with all health needs. This commentary suggests a four-point contextualised mitigation plan to safeguard MNCH care during the pandemic using the observed countries as exemplars for LMIC health system adaptations to maintain the trajectory of progress regarding sustainable development goals (SDGs).


Assuntos
/prevenção & controle , Serviços de Saúde da Criança , Controle de Doenças Transmissíveis/métodos , Utilização de Instalações e Serviços/tendências , Serviços de Saúde Materna , Adulto , Bangladesh , Criança , Países em Desenvolvimento , Feminino , Humanos , Nigéria , Gravidez , Saúde Pública/legislação & jurisprudência , Quarentena/legislação & jurisprudência , África do Sul , Populações Vulneráveis
14.
N Z Med J ; 134(1529): 80-85, 2021 02 05.
Artigo em Inglês | MEDLINE | ID: mdl-33582710

RESUMO

Diabetes is one of the most common chronic disorders in emerging adults (15-25 years of age), and the prevalence of both type 1 diabetes (T1D) and type 2 diabetes (T2D) in New Zealand continues to increase in this age group. Tight glycaemic control in both T1D and T2D is well known to reduce diabetic microvascular and macrovascular complications and improve survival. However, in New Zealand and worldwide, emerging adulthood is typically the period of worst glycaemic control in the lifespan due to the high prevalence of psychosocial stressors and increased insulin resistance of puberty and risk-taking behaviours. In addition, the glycaemic control of emerging adults with diabetes in New Zealand often deteriorates due to the loss of support from family and friends from moving regions, the failure of support from paediatric services to extend to emerging adulthood and the loss of public funding for insulin pump therapy as glycaemic targets are no longer met. Given the high prevalence of psychosocial stressors and the loss of support, the International Society for Paediatric and Adolescent Diabetes's (ISPAD's) guidelines recommend that emerging adults with diabetes receive ambulatory care from a dedicated multidisciplinary team consisting of 0.75 full time equivalent (FTE)/100 patients of an endocrinologist, 1-1.25 FTE/100 patients of a diabetes nurse specialist, 0.5 FTE/100 patients of a dietitian, 0.3 FTE/100 patients of a psychologist and 0.3 FTE/100 patients of a social worker or youth worker.


Assuntos
Serviços de Saúde da Criança/estatística & dados numéricos , Diabetes Mellitus Tipo 1/terapia , Diabetes Mellitus Tipo 2/terapia , Endocrinologistas/provisão & distribuição , Mão de Obra em Saúde/estatística & dados numéricos , Adolescente , Adulto , Criança , Serviços de Saúde da Criança/organização & administração , Diabetes Mellitus Tipo 1/epidemiologia , Diabetes Mellitus Tipo 2/epidemiologia , Gerenciamento Clínico , Feminino , Pesquisas sobre Serviços de Saúde , Humanos , Masculino , Nova Zelândia/epidemiologia , Equipe de Assistência ao Paciente/estatística & dados numéricos , Adulto Jovem
16.
Artigo em Inglês | MEDLINE | ID: mdl-33547004

RESUMO

Telehealth in the broadest sense has been used by pediatric clinicians for over a century, as telephone triage has been and continues to be an essential part of pediatric practice. Utilizing more advanced technology including video communication, although available, was generally underutilized until the onset of the COVID-19 pandemic. Telehealth presents the opportunity to bridge many divides including geographical and logistical challenges. Many acute pediatric conditions can be managed safely and effectively through telehealth especially when remote physical exam equipment is used. Telehealth can also be especially useful in medical care of children with medical complexity. Traveling with medical equipment to multiple subspecialists can be incredibly challenging and often a similar quality visit can be conducted through telehealth in the comfort of a child's home environment. Well child care presents a unique problem while trying to maintain social distancing. Integrating a hybrid model using both an in-person exam and history through video conferencing can help balance limited face to face time with the need to ensure a full and appropriate physical exam. Integration of telehealth into the pediatric patient centered medical home can enable families to gain convenience while maintaining the essential relationship with their primary care office.


Assuntos
/epidemiologia , Serviços de Saúde da Criança/organização & administração , Pediatria/organização & administração , Atenção Primária à Saúde/organização & administração , Telemedicina/organização & administração , Doença Aguda , Criança , Doença Crônica , Humanos , Pandemias
17.
BMJ Open ; 11(2): e042095, 2021 02 18.
Artigo em Inglês | MEDLINE | ID: mdl-33602705

RESUMO

OBJECTIVE: We assessed whether geographic distance and difference in altitude between home to health facility and household socioeconomic status were associated with utilisation of maternal and child health services in rural Ethiopia. DESIGN: Household and health facility surveys were conducted from December 2018 to February 2019. SETTING: Forty-six districts in the Ethiopian regions: Amhara, Oromia, Tigray and Southern Nations, Nationalities, and Peoples. PARTICIPANTS: A total of 11 877 women aged 13-49 years and 5786 children aged 2-59 months were included. OUTCOME MEASURES: The outcomes were four or more antenatal care visits, facility delivery, full child immunisation and utilisation of health services for sick children. A multilevel analysis was carried out with adjustments for potential confounding factors. RESULTS: Overall, 39% (95% CI: 35 to 42) women had attended four or more antenatal care visits, and 55% (95% CI: 51 to 58) women delivered at health facilities. One in three (36%, 95% CI: 33 to 39) of children had received full immunisations and 35% (95% CI: 31 to 39) of sick children used health services. A long distance (adjusted OR (AOR)=0.57; 95% CI: 0.34 to 0.96) and larger difference in altitude (AOR=0.34; 95% CI: 0.19 to 0.59) were associated with fewer facility deliveries. Larger difference in altitude was associated with a lower proportion of antenatal care visits (AOR=0.46; 95% CI: 0.29 to 0.74). A higher wealth index was associated with a higher proportion of antenatal care visits (AOR=1.67; 95% CI: 1.02 to 2.75) and health facility deliveries (AOR=2.11; 95% CI: 2.11 to 6.48). There was no association between distance, difference in altitude or wealth index and children being fully immunised or seeking care when they were sick. CONCLUSION: Achieving universal access to maternal and child health services will require not only strategies to increase coverage but also targeted efforts to address the geographic and socioeconomic differentials in care utilisation, especially for maternal health. TRIAL REGISTRATION NUMBER: ISRCTN12040912.


Assuntos
Serviços de Saúde da Criança , Serviços de Saúde Materna , Adolescente , Adulto , Altitude , Criança , Pré-Escolar , Estudos Transversais , Etiópia , Feminino , Humanos , Lactente , Pessoa de Meia-Idade , Análise Multinível , Aceitação pelo Paciente de Cuidados de Saúde , Gravidez , Cuidado Pré-Natal , Fatores Socioeconômicos , Adulto Jovem
18.
Cochrane Database Syst Rev ; 2: CD012882, 2021 02 10.
Artigo em Inglês | MEDLINE | ID: mdl-33565123

RESUMO

BACKGROUND: The leading causes of mortality globally in children younger than five years of age (under-fives), and particularly in the regions of sub-Saharan Africa (SSA) and Southern Asia, in 2018 were infectious diseases, including pneumonia (15%), diarrhoea (8%), malaria (5%) and newborn sepsis (7%) (UNICEF 2019). Nutrition-related factors contributed to 45% of under-five deaths (UNICEF 2019). World Health Organization (WHO) and United Nations Children's Fund (UNICEF), in collaboration with other development partners, have developed an approach - now known as integrated community case management (iCCM) - to bring treatment services for children 'closer to home'. The iCCM approach provides integrated case management services for two or more illnesses - including diarrhoea, pneumonia, malaria, severe acute malnutrition or neonatal sepsis - among under-fives at community level (i.e. outside of healthcare facilities) by lay health workers where there is limited access to health facility-based case management services (WHO/UNICEF 2012). OBJECTIVES: To assess the effects of the integrated community case management (iCCM) strategy on coverage of appropriate treatment for childhood illness by an appropriate provider, quality of care, case load or severity of illness at health facilities, mortality, adverse events and coverage of careseeking for children younger than five years of age in low- and middle-income countries. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase and CINAHL on 7 November 2019, Virtual Health Library on 8 November 2019, and Popline on 5 December 2018, three other databases on 22 March 2019 and two trial registers on 8 November 2019. We performed reference checking, and citation searching, and contacted study authors to identify additional studies. SELECTION CRITERIA: Randomized controlled trials (RCTs), cluster-RCTs, controlled before-after studies (CBAs), interrupted time series (ITS) studies and repeated measures studies comparing generic WHO/UNICEF iCCM (or local adaptation thereof) for at least two iCCM diseases with usual facility services (facility treatment services) with or without single disease community case management (CCM). We included studies reporting on coverage of appropriate treatment for childhood illness by an appropriate provider, quality of care, case load or severity of illness at health facilities, mortality, adverse events and coverage of careseeking for under-fives in low- and middle-income countries. DATA COLLECTION AND ANALYSIS: At least two review authors independently screened abstracts, screened full texts and extracted data using a standardised data collection form adapted from the EPOC Good Practice Data Collection Form. We resolved any disagreements through discussion or, if required, we consulted a third review author not involved in the original screening. We contacted study authors for clarification or additional details when necessary. We reported risk ratios (RR) for dichotomous outcomes and hazard ratios (HR) for time to event outcomes, with 95% confidence intervals (CI), adjusted for clustering, where possible. We used estimates of effect from the primary analysis reported by the investigators, where possible. We analysed the effects of randomized trials and other study types separately. We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS: We included seven studies, of which three were cluster RCTs and four were CBAs. Six of the seven studies were in SSA and one study was in Southern Asia. The iCCM components and inputs were fairly consistent across the seven studies with notable variation for the training and deployment component (e.g. on payment of iCCM providers) and the system component (e.g. on improving information systems). When compared to usual facility services, we are uncertain of the effect of iCCM on coverage of appropriate treatment from an appropriate provider for any iCCM illness (RR 0.96, 95% CI 0.77 to 1.19; 2 CBA studies, 5898 children; very low-certainty evidence). iCCM may have little to no effect on neonatal mortality (HR 1.01, 95% 0.73 to 1.28; 2 trials, 65,209 children; low-certainty evidence). We are uncertain of the effect of iCCM on infant mortality (HR 1.02, 95% CI 0.83 to 1.26; 2 trials, 60,480 children; very low-certainty evidence) and under-five mortality (HR 1.18, 95% CI 1.01 to 1.37; 1 trial, 4729 children; very low-certainty evidence). iCCM probably increases coverage of careseeking to an appropriate provider for any iCCM illness by 68% (RR 1.68, 95% CI 1.24 to 2.27; 2 trials, 9853 children; moderate-certainty evidence). None of the studies reported quality of care, severity of illness or adverse events for this comparison. When compared to usual facility services plus CCM for malaria, we are uncertain of the effect of iCCM on coverage of appropriate treatment from an appropriate provider for any iCCM illness (very low-certainty evidence) and iCCM may have little or no effect on careseeking to an appropriate provider for any iCCM illness (RR 1.06, 95% CI 0.97 to 1.17; 1 trial, 811 children; low-certainty evidence). None of the studies reported quality of care, case load or severity of illness at health facilities, mortality or adverse events for this comparison. AUTHORS' CONCLUSIONS: iCCM probably increases coverage of careseeking to an appropriate provider for any iCCM illness. However, the evidence presented here underscores the importance of moving beyond training and deployment to valuing iCCM providers, strengthening health systems and engaging community systems.


Assuntos
Administração de Caso/organização & administração , Serviços de Saúde da Criança/organização & administração , Agentes Comunitários de Saúde , Países em Desenvolvimento , África ao Sul do Saara , Ásia , Viés , Pré-Escolar , Agentes Comunitários de Saúde/economia , Agentes Comunitários de Saúde/educação , Agentes Comunitários de Saúde/organização & administração , Estudos Controlados Antes e Depois , Diarreia/terapia , Febre/terapia , Humanos , Lactente , Mortalidade Infantil , Transtornos da Nutrição do Lactente/terapia , Recém-Nascido , Malária/terapia , Sepse Neonatal/terapia , Pneumonia/terapia , Ensaios Clínicos Controlados Aleatórios como Assunto , Salários e Benefícios , Nações Unidas
19.
BMC Health Serv Res ; 21(1): 185, 2021 Feb 27.
Artigo em Inglês | MEDLINE | ID: mdl-33639929

RESUMO

BACKGROUND: The medical home (MH) model has been promoted by both the federal and state governments in the United States in recent years. To ascertain American children's MH status, many studies have relied on a large set of survey items, posing a considerable burden on their parents. We aimed to identify individual survey items or domains that best predict MH status for children and use them to develop brief markers of MH status. We also examined whether the identified items differed by status of special health care needs and by racial/ethnic group. METHOD: Using the 9-year data from Medical Expenditure Panel Survey, we examined associations between children's MH status and individual survey items or domains. We randomly split the data into two halves with the first half (training sample, n = 8611) used to identify promising items, and the second half (validation sample, n = 8779) used to calculate all statistical measures. After discovering significant predictors of children's MH status, we incorporated them into several brief markers of MH status. We also conducted stratified analyses by status of special health care needs and by racial/ethnic group. RESULTS: Less than half (48.7%) of the 8779 study children had a MH. The accessibility domain has stronger association with children's MH status (specificity = 0.84, sensitivity = 1, Kappa = 0.83) than other domains. The top two items with the strongest association with MH status asked about after-hours primary care access, including doctors' office hours at night or on the weekend and children's difficulty accessing care after hours. Both belong to the accessibility domain and are one of several reliable markers for children's MH status. While each of the two items did not differ significantly by status of special health care needs, there were considerable disparities across racial/ethnic groups with Latino children lagging behind other children. CONCLUSION: Accessibility, especially the ability to access health care after regular office hours, appears to be the major predictor of having a MH among children. The ongoing efforts to promote the MH model need to target improving accessibility of health care after regular hours for children overall and especially for Latino children.


Assuntos
Serviços de Saúde da Criança , Criança , Pesquisas sobre Serviços de Saúde , Acesso aos Serviços de Saúde , Hispano-Americanos , Humanos , Assistência Centrada no Paciente , Estados Unidos
20.
BMJ Open ; 11(1): e040109, 2021 01 20.
Artigo em Inglês | MEDLINE | ID: mdl-33472778

RESUMO

INTRODUCTION: Improving the impact of nutrition interventions requires adequate measurement of both reach and quality of interventions, but limited evidence exists on advancing coverage measurement. We adjusted contact-based coverage estimates, taking into consideration the inputs required to deliver quality nutrition services, to calculate input-adjusted coverage of nutrition interventions across the continuum of care from pregnancy through early childhood in Bangladesh. METHODS: We used data from the 2014 Bangladesh Demographic and Health Surveys to assess use of maternal and child health services and the 2014 Service Provision Assessment to determine facility readiness to deliver nutrition interventions. Service readiness captured availability of nutrition-specific inputs (including human resources and training, equipment, diagnostics and medicines). Contact coverage was combined with service readiness to create a measure of input-adjusted coverage at the national and regional levels, across place of residence, and by maternal education and household socioeconomic quintiles. RESULTS: Contact coverage varied from 28% for attending at least four ANC visits to 38% for institutional delivery, 35% for child growth monitoring and 81% for sick child care. Facilities demonstrated incomplete readiness for nutrition interventions, ranging from 48% to 51% across services. Nutrition input-adjusted coverage was suboptimal (18% for ANC, 23% for institutional delivery, 20% for child growth monitoring and 52% for sick child care) and varied between regions within the country. Inequalities in input-adjusted coverage were large during ANC and institutional delivery (14-17 percentage points (pp) between urban and rural areas, 15 pp between low and high education, and 28-34 pp between highest and lowest wealth quintiles) and less variable for sick child care (<2 pp). CONCLUSION: Nutrition input-adjusted coverage was suboptimal and varied subnationally and across the continuum of care in Bangladesh. Special efforts are needed to improve the reach as well as the quality of health and nutrition services to achieve the Sustainable Development Goals.


Assuntos
Serviços de Saúde da Criança , Instalações de Saúde , Bangladesh , Criança , Pré-Escolar , Continuidade da Assistência ao Paciente , Estudos Transversais , Feminino , Pesquisas sobre Serviços de Saúde , Humanos , Gravidez , Cuidado Pré-Natal , Fatores Socioeconômicos
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