Global Health: Science and Practice最新文献

Background: Rapid analysis of community needs, perspectives, and concerns during global health emergencies is essential but technically challenging. In the past, emergency responders have struggled to listen to and engage affected communities because of perceptions about anticipated costs and time delays in receiving actionable results.

Tool development: The U.S. Centers for Disease Control and Prevention Excel Tool for Thematic Analysis was developed over 5 years of assisting with emergency responses for Ebola, COVID-19, Sudan Ebolavirus, mpox, and the Ukraine crisis. Beginning with a simple Excel spreadsheet for coding Ebola-related community feedback, we continued to add new features as needs arose, such as preloaded epidemic and health emergency coding schemes, preprogrammed results tables, step-by-step thematic analysis instruction, YouTube training videos, and planning and communication tools for effective use of the results.

Implementation: The tool is a customized Excel workbook for qualitative text coding and thematic analysis that enables the user to code and derive key themes from texts, such as interview and focus group transcripts, notes, surveys with open-ended questions, and social media comments. We review the 10 programmed worksheets for planning, cataloguing, coding, and thematically analyzing any kind of text data.

Conclusion: The strategies for rapid community feedback analysis during health emergencies are a special application of qualitative analysis methodology to the health emergency setting, enabling a deep reading and transparent and defensible interpretation of the text. Skills learned while using the tool are easily transferable to analyses using licensed software or fully manual methods. The tool offers a step-by-step guide for anyone to analyze text data to answer a relevant question in or outside the context of emergencies.

Introduction: Cesarean delivery, peripartum hysterectomy, female genital fistula treatment, and long-acting and permanent contraceptive method provision comprise an important set of surgical procedures in reproductive and maternal health. The volume of these procedures is growing in low- and middle-income countries (LMICs). Establishing research priorities in a learning agenda for surgical obstetrics and family planning represents a key step in generating and using evidence to improve health outcomes associated with these surgeries.Methods: Between January and February 2022, a safe surgery project addressing family planning and obstetrics used a 2-stage rating and ranking consultation process to prioritize topics in its learning agenda, focusing on LMIC needs. A list of research and learning topics spanning the project's technical areas, consisting of surgical obstetric care (cesarean delivery and peripartum hysterectomy), fistula prevention and treatment, family planning, and cross-cutting safe surgery, was curated by searching the literature, conducting project-related surveys of experts and partners, and soliciting an expert panel via virtual consultation. Through an online survey, the experts rated the 63 topics on a 5-point scale based on 4 criteria-feasibility, technical importance, level of saturation, and potential for impact-and average ratings were calculated for each criterion and topic. The expert panel then reconvened virtually to rank and refine highly rated topics.Results: A total of 39 people participated in the expert panel, representing multilateral, academic, and funding organizations, implementing partners, and professional associations active in LMICs. Fifteen topics were prioritized across the 4 technical areas. Prioritized topics covered themes of prevention (e.g., intrapartum/midwifery practices to prevent unnecessary cesarean delivery), care-seeking (e.g., social and behavior change strategies for fistula prevention), perioperative care (e.g., use of quality improvement tools including checklists and audits), and postoperative care (e.g., effective measurement approaches for monitoring outcomes).Conclusion: This agenda guides clinical and programmatic learning across the safe surgery ecosystem. Collaborative action across program initiatives and clinical and community settings may contribute to significant evidence building in these priority topics.

Background: Promoting client-centered care (CCC) has been a long-standing goal for sexual and reproductive health (SRH) programs. MSI Reproductive Choices (MSI), a global SRH service delivery organization, set out to fully operationalize CCC delivery utilizing a new strategic framework and measurement approach.

Development of the approach: The framework was developed by a global technical group at MSI, based on a literature review, country pilots in Nepal and Zambia, and practical experience in service delivery and quality improvement. It is based on a socioecological model, recognizing that SRH client experience is determined by the behavior of the provider, the managerial support given to providers, and the broader organizational culture. The accompanying composite CCC metric assesses performance across these 3 levels annually using program monitoring tools. A digital results dashboard links to a suite of guidance and tools to support CCC improvement.

Lessons learned: SRH programs in 28 countries have been monitoring their progress on CCC since 2021, and a majority have made improvements in their CCC performance since then. Using the annual CCC results, global support staff and country managers have selected interventions based on local needs, including CCC training, client feedback systems, and client experience checklists. Implementation of a global staff engagement survey has been instrumental in CCC measurement, complementing preexisting client exit interview and quality audit processes. A global CCC monitoring process allows sharing of successes and positive practice, and staff have supported and championed CCC.

Conclusion: Recognizing the critical influences of provider support and engagement as well as broader organizational culture has been pivotal in scaled operationalization of CCC within SRH programs. The simple framework and accompanying metric can be adapted to fit available tools and data systems in other institutions to support attainment of the highest standards of quality care and respect for client rights.

In 2018, the Government of India launched the Anemia Mukt Bharat (AMB) program to accelerate reductions in the prevalence of anemia among children aged 6-59 months, children aged 5-9 years, adolescents aged 10-19 years, pregnant women, and lactating mothers through 6 programmatic interventions and 6 institutional mechanisms. We describe the process of computing the AMB index, aimed at providing timely and systematic information on iron and folic acid (IFA) supplementation coverage across these groups to aid in evaluating the effectiveness of the program. This study presents data from fiscal year 2018-2019 to 2022-2023 on IFA supplementation coverage among these 5 groups. We calculated the AMB index that provides an average for IFA supplementation coverage for target groups. Data on the target groups were acquired from the AMB dashboard, and information on IFA supplementation coverage was sourced from the health management information system. The AMB index confirmed that between 2018-2019 and 2022-2023 IFA supplementation coverage increased overall in India by 22.1 percentage points, from 35.5% to 57.6%. During this period, IFA supplementation coverage increased for all target groups including pregnant women, children aged 6-59 months, children 5-9 years, adolescents aged 10-19 years, and lactating mothers. The supply chain management and reporting of the data on the portal were among the key factors that substantially impacted the IFA supplementation coverage. The IFA supplementation coverage will significantly increase if the IFA supply chain and reporting standards improve. We discuss the policy implications and suggestions to improve the overall IFA supplementation coverage across India.

In the management of chronic conditions like HIV, the continuity of service delivery is necessary to achieve desired outcomes, such as HIV viral load suppression, behavioral change, improved health, and client satisfaction. The transition phase-when a project closes and another starts-is a potential period of service delivery disruption. Active management of this transition period is important to prevent disruptions, especially for key populations who may be stigmatized and have limited options for accessing HIV services. We analyzed this transition period between July and December 2022 between 2 projects that provided HIV prevention services, management of sexually transmitted infections, and linkage to HIV treatment and other complementary services to key populations in Zambia. To ensure a smooth project transition, we implemented a set of interventions, including joint planning for project transition, strategic leadership, trust-building initiatives, active community and stakeholder engagement, repeated stakeholder reassurance, open communication, and transparent data sharing. After transitioning to the new project, we noted that all 3 service types of interest experienced at least a 20% increase over the levels achieved in the last month of the closing project. This increase contrasts with the assumption that all service types delivered through project structures would decline to zero persons reached within 2 months of project closing if the next project did not commence seamlessly. The decrease in service delivery was averted with the intentional transition interventions. Additionally, we recorded operational gains, such as stakeholder satisfaction, adequate assets transfer, stability in project service delivery location, and reduced personnel anxiety. We conclude that active multipartite management of the transition phase for projects is essential for ensuring uninterrupted service delivery and sustaining good outcomes for clients. Donors, health system managers, and program managers should actively require and design sound transition management plans as part of their program designs. In the aftermath of recent abrupt cuts in US Government development sector funding that allowed no planned transitions, it is important that surviving programs carefully imbibe lessons shared in this paper to protect years-and sometimes decades-of program gains.

The Uganda Public Health Fellowship Program (UPHFP) is a 2-year, non-degree-granting field epidemiology training program. It enrolls only post-Master's degree fellows, who are integrated during their training into key Ministry of Health (MOH) programs, such as the National Malaria Control Program, and supported technically and financially by the U.S. President's Malaria Initiative (PMI) and U.S. Centers for Disease Control and Prevention. However, the nature and extent of the UPHFP contributions to the malaria control programs have not been systematically documented. We describe how the UPHFP strategies contributed to malaria control programs and share implementation challenges and opportunities to inform future programming. From 2015 to 2022, UPHFP led or supported 50 malaria projects, including 14 malaria surveillance projects, 11 malaria outbreak investigations, 7 epidemiological studies, 5 case studies, 6 malaria quality improvement projects, 3 policy briefs, and 4 training and mentorship projects. These projects have informed policy decisions and strengthened surveillance, coordination, and response to malaria outbreaks. A key challenge is single-source funding that makes the program more vulnerable to changes in donor priorities. Our documentation demonstrates the critical value of UPHFP to the country's malaria control efforts by enhancing epidemiologic workforce capacity and strengthening epidemiological surveillance.

Introduction: The experiences of people who interact with a health system form a key component of overall quality of care in that system. Yet, client experience is rarely reflected in how health systems are designed and assessed. To make meaningful progress on delivering high-quality patient-centered care, health systems actors need valid measures of client experience of care. However, no cross-cutting measure of client experience of care exists at present that could facilitate measurement and benchmarking across multiple health service areas.

Methods: We conducted a phased literature search using multiple scholarly databases to identify peer-reviewed articles detailing the development, validation, or adaptation of measures relating to the concept of client experience in sexual and reproductive health care, HIV, primary care, noncommunicable disease management, and health services management and marketing. Measure domains were thematically analyzed and mapped against domains of an existing client experience of care framework-effective communication, respect and dignity, and emotional support.

Results: We identified 73 articles that met inclusion criteria and that recounted the development, validation, or adaptation of 61 different measures of health care quality and responsiveness. Numerous measures exhibited significant overlap with an existing conceptual framework for client experience, but few measures were used across health areas.

Discussion: Content of many of the measures identified in this review mapped closely to domains that appear in an existing framework for client experience of care, including effective communication, respect and dignity, and emotional support. These findings support the notion that developing a generalizable measure of client experience of care could be technically feasible.

In response to the 2020 COVID-19 pandemic, a nongovernmental organization in Nepal piloted a maternal and newborn health helpline program in partnership with the Government of Nepal and the Nepal Society of Obstetricians and Gynaecologists. The program connected service providers in remote areas with real-time clinical support during obstetric and neonatal emergencies via telephone consultations with clinical experts. 551 primary health care facilities across 14 districts of Nepal were included in the program and connected to a roster of 33 clinical expert volunteers from district or tertiary care hospitals. To assess the results of the program, we collected both quantitative and qualitative data, including monthly health facility record reviews from July 2020 to June 2021 and semi-structured interviews with clinical experts and service providers conducted in June 2021. Of the 551 health facilities included in the program, 160 facilities (29%) reported using the helpline during the study period, with 429 teleconsultation cases recorded. We found that 21% of these cases that otherwise would have been referred to a hospital were effectively managed by telephone on-site at rural health facilities, revealing the promising potential for impact using a low-tech solution. Of the health facilities that participated in the program, the helpline was predominantly used in remote facilities where access to higher-level referral centers for emergencies was limited. Feedback from both experts and service providers revealed that the program helped to improve clinical decision-making during emergencies, build confidence and skills of service providers, and improve referral efficiency. Implementation challenges included service providers' underreporting of helpline utilization, a lack of essential drugs at primary health care facilities, unreliable phone signals, and a lack of financial incentives for clinical experts. The results and implementation experiences shared in this article provide a template for the design and implementation of similar support programs for service providers managing clinical emergencies in rural contexts.

Introduction: Many pregnancy-related deaths can be avoided if health care workers reliably provide prompt, evidence-based care during the final stages of pregnancy and delivery. We report the impact on the institutional maternal mortality ratio (iMMR) of a quality improvement (QI) initiative that focused on establishing timely and reliable obstetric care in public Brazilian hospitals for the primary causes of maternal deaths.Methods: The QI initiative used a quasi-experimental time-series design implemented in 19 Brazilian maternity hospitals comparing 3 periods: baseline (January 2018 to November 2019), implementation (December 2019 to March 2021), and post-implementation (April 2021 to September 2021). We used a sequential approach, referred to as the "4Rs" (Recognize, Rescue, Reassess, and Refer), with the Modified Early Obstetric Warning Score (MEOWS) as a key tool, to identify clinical deterioration and implement care bundles directed at the management of 3 principal life-threatening conditions around the time of birth: postpartum hemorrhage, sepsis, and hypertensive disorders of pregnancy (HDPs). Clinical staff received tailored training and support within a structured learning system that brought multiple teams together to rapidly test and implement evidence-based changes.Results: Comparing the baseline with the implementation period, run charts detected an overall reduction of 34.2% in all causes of maternal deaths (from 83.7 to 55 deaths per 100,000 live births). Additionally, the iMMR due to the 3 analyzed life-threatening conditions decreased by 60.9% between baseline and the combined implementation and post-implementation periods (from 44.1 to 17.2 deaths per 100,000 live births); postpartum hemorrhage-related deaths were reduced by 72.9% (from 11.7 to 3.17 deaths per 100,000 live births) and sepsis-related deaths were reduced by 100% (from 20.4 to 0 deaths per 100,000 liv births). No changes by HDP-related deaths were observed. There was a 178% increase in iMMR by all causes (mainly attributed to COVID-19) during the post-implementation period, but deaths related to life-threatening conditions either remained stable or decreased even further.Conclusion: Optimization of the steps in a care sequence and reliable implementation of care bundles directed at the principal life-threatening conditions around the time of birth, using QI, tailored training, and the MEOWS tool, seem to be feasible and promising approaches for reducing iMMR.