Global Health: Science and Practice最新文献

Introduction: Timely access to emergency obstetric care (EmOC) remains a challenge in sub-Saharan Africa, influenced by poor health care utilization and rapid urbanization. Studies show poor maternal health outcomes in African cities, reflecting weak health systems. Understanding care-seeking pathways is key to improving service delivery and health outcomes. We examined self-reported care-seeking pathways among women with obstetric complications in Kampala City, Uganda.

Methods: In this cross-sectional survey, we collected sequential data from 433 women (15-49 years) from 9 health facilities in Kampala City. We developed typologies of common pathways to EmOC and descriptively analyzed key attributes, including median time spent at each step, comparing pathways across complications and participant characteristics. Provider utilization and service delivery performance issues were also assessed.

Results: Participants' average age was 26 years (standard deviation=6), with 55% (237/433) living outside Kampala. We identified 4 common pathways based on number and location of steps: pathways with 1 step, directly to a facility that provided required care (42%, 183/433); 2 steps, mostly including direct facility referrals (40%, 171/433); 3 steps (14%, 62/433); and 4 or more steps (4%, 17/433). Comprehensive EmOC facilities referred elsewhere 43% (79/184) of women who initially sought care in these facilities. Peripheral facilities referred 65% of women directly to the national referral hospital. A majority (60%, 34/57) of referred women returned home before reaching the final care facility.

Conclusions: Our findings suggest that care pathways of women with obstetric complications in Kampala often involve at least 2 formal providers and reflect possible inefficiencies in the referral process, including potential delays and unnecessary steps. Efforts to strengthen urban health and referral systems should adopt multidisciplinary and integrated approaches, supported by clear policies and structures that facilitate effective interfacility and interdistrict care coordination. This should include streamlined care/referral pathways and equitable emergency transportation systems.

Introduction: As part of a laboratory strengthening program in Malawi to achieve and maintain International Organization for Standardization (ISO) 15189 accreditation, we intended to mentor selected HIV molecular laboratories to achieve this accreditation. Due to the COVID-19 pandemic, mentorship pivoted to a hybrid model using an Internet-based approach and on-site mentorships. We describe the implementation of this strategy, successes, and challenges.

Methods: We conducted weekly, 1-hour virtual mentorship sessions for the 5 initial laboratories (cohort 1) selected based on their Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA) performance score of 3 or more stars. Laboratories presented updates and supporting documents electronically, and trainings were conducted virtually. In September 2020, when travel restrictions were relaxed, we initiated hybrid mentorships and audits for cohort 1 laboratories. The same hybrid approach was used to mentor 4 additional laboratories in cohort 2. We performed descriptive analysis, and the Wilcoxon signed-rank test was used to compare the training pre-and post-test scores.

Results: Between March 2020 and May 2023, the team completed a total of 54 virtual mentorship sessions and 20 on-site visits across 9 laboratories. Overall, the team conducted 8 training sessions for 35 laboratory quality officers. Median score improvement (pre-test vs. post-test scores) was observed across individual trainings and across cohorts (P<.01). At the end of cohort 1, 4 of 5 (80%) laboratories were accredited. One laboratory that did not reach accreditation joined cohort 2. At the end of the mentoring period, all 5 cohort 2 laboratories were accredited.

Conclusions: We demonstrated that using a hybrid mentorship model for accreditation was a successful strategy during the COVID-19 pandemic. For the first time in Malawi, this strategy resulted in accrediting 9 of the 10 HIV molecular laboratories in 3 years at a reduced cost. Continuous mentorship is key in the maintenance of accreditation.

Health information systems (HISs) are essential to a country's health system as they provide critical support to health policymaking, management, financing, and service delivery. A well-functioning HIS should produce timely and reliable data that are available and easily accessible to decision-makers throughout the health system. Ethiopia has transitioned from a fragmented, paper-based health management information system (HMIS) to a harmonized, digital system used at points of collection and service delivery.In 2016, the Federal Ministry of Health (MOH) launched the Information Revolution (IR), a transformative agenda aimed at enhancing the culture of data use, scaling priority HIS tools and systems, and strengthening HIS governance. Between 2016 and 2022, the MOH, Data Use Partnership, and other partners implemented a series of IR interventions that supported this agenda. These interventions included deploying and harmonizing digital HIS systems; strengthening HIS leadership, coordination, and governance; implementing the IR pathway strategy; enhancing capacity through supportive supervision, mentorship, and training; and improving performance monitoring teams. This article aims to synthesize the key HIS interventions implemented in Ethiopia as part of the IR and document the effects of these interventions on HIS performance.Early studies indicate promising improvements in HIS performance across health facilities in Ethiopia. However, challenges remain. To ensure sustainable progress, it is essential to continue addressing key challenges, such as system interoperability, HIS workforce, and capacity for data use at all levels. By building on the successes of the first Health Sector Transformation Plan and addressing these gaps, Ethiopia can advance its vision of a robust, data-driven health system capable of improving health outcomes and driving evidence-based decision-making.

Introduction: In Argentina, the implementation of a national strategy to reduce the prevalence of noncommunicable diseases (NCDs) has been hampered by challenges at the provincial level. We aimed to design a new model of care for NCDs at the primary care level by conducting a multimodal system assessment and co-design of potential solutions in the province of Mendoza.

Methods: We carried out a mixed-methods study with 7 components: evaluation of patterns of care, patient focus groups, cross-sectional standardized population-based phone survey, an electronic cohort follow-up of patients with type 2 diabetes, in-depth interviews with stakeholders, a knowledge test for health care providers on chronic condition management, and a Delphi consensus to provide recommendations from stakeholders.

Results: Focus group and in-depth interviews revealed access to primary health care for NCDs was associated with problems with long waiting times and time-consuming procedures for referral to laboratory tests, hospital care, and provision of medication. Mental health care services were particularly limited. Survey respondents (N=1,190) were predominantly covered through public (41%) or social security sectors (54%); 41% fell in the lowest income group. Contact with the health system was high (5.7 annual visits), but 19.7% reported unmet health care needs. Public sector providers perceived they provided high-quality care despite insufficient material and human resources. Within the social security sector, the main challenge was insufficient staff, particularly affecting mental health care. Health care providers showed a higher percentage of correct answers to depression-related questions, but worse results were seen in hypertension and diabetes care. Actions supported by evidence and expert agreement were identified for implementation to guide future system changes.

Conclusion: Our research highlights the potential for Argentina's primary care system to initiate transformative, system-level changes aimed at improving health outcomes. We propose an innovative methodological assessment and co-design for improving primary care.

Mental health (MH) disorders are highly prevalent among people living with HIV and can have a negative impact on antiretroviral therapy (ART) outcomes. Malawi's Ministry of Health introduced MH screening in national HIV management guidelines in 2022. We describe early experience with integrated MH screening at ART clinics that have scarce human resources and limited capacity of specialist MH units. ART staff in 15 facilities were trained to use the Patient Health Questionnaire-9 (depression) and the Alcohol Use Disorders Identification Test (harmful alcohol use) screening instruments, MH registers were developed for tracking screening results and referrals, and existing MH referral units were engaged. Based on screening results, ART clients received counseling by lay cadre staff (for mild symptoms) or intensive counseling by trained psychosocial counselors and referrals to specialist MH units (for moderate to severe symptoms). From October 2022 through July 2023, 9,826 ART clients were screened from the following priority groups: returning to care after an interruption in treatment (50%), newly diagnosed (38%), and viral load ≥1,000 copies/mL (12%). Of those screened, 59% were female and 14% were aged 12-19 years. Screening coverage was 85% (9,826/11,553) among the 3 priority groups. All of the individuals who screened positive for moderate/severe depression (1.1%; n=106) or high risk for harmful alcohol use (2.3%; n=227) were referred to specialist MH units. In conclusion, thorough preparation led to high MH screening coverage among ART priority groups, and the number of referrals to specialist MH units was low. MH screening was feasible at Malawi ART clinics. Next steps include studying the clinical impact of integrated MH screening on MH outcomes and ART outcomes (retention in care and viral suppression) and scaling up integrated MH screening to all ART clinics.

Introduction: We evaluated the Informed Health Choices secondary school intervention to help students in Kenya think critically about health choices. We conducted this process evaluation to explore if the intervention was implemented as planned, identify factors that facilitated or hindered implementation, potential benefits of the intervention, and how to scale up the intervention beyond the trial.

Methods: This was a mixed methods process evaluation nested in a cluster-randomized trial of the Informed Health Choices intervention. We analyzed quantitative data from teacher training evaluation forms completed by 39 teachers, 10 lesson evaluation forms completed by 40 teachers allocated to the intervention, and 72 structured classroom observation forms. We conducted a framework analysis of qualitative data from 14 group interviews (with 96 students, 23 teachers, and 18 parents) and 22 individual interviews (with 8 teachers, 5 school principals, 6 curriculum developers, and 3 policymakers). We assessed confidence in our findings from the qualitative analysis using a modified version of Confidence in the Evidence from Reviews of Qualitative Research.

Results: Lesson objectives were achieved with minimal adaptations. Factors that might have facilitated the implementation of the intervention include teacher training; perceived value of the intervention by students, teachers, and policymakers; and support from school administration. Time constraints, teachers' heavy workloads, and the lessons not being included in the curriculum or national examination are factors that might have impeded implementation. Both students and teachers demonstrated the ability to apply key concepts that were taught to health choices and other choices. However, they experienced difficulties with 2 of the lessons.

Conclusion: Scale-up of this intervention in Kenyan schools is feasible but may depend on adjusting the time allocated to teaching the lessons, modifying the 2 lessons that teachers and students found difficult, and including the lesson objectives and assessment in the national curriculum.