Journal of Health Services Research & Policy最新文献

Objective: Little is known about how to achieve scale and spread beyond the early local adoption of an innovative health care programme. We use the New Care Model - or 'Vanguard' - programme in the English National Health Service to illuminate the process, assessing why only one of five Vanguard programmes was successfully scaled up.

Methods: We interviewed a wide range of stakeholders involved in the Vanguard programme, including programme leads, provider organisations, and policymakers. We also consulted relevant documentation.

Results: A lack of direction near the end of the Vanguard programme, a lack of ongoing resources, and limited success in providing real-time monitoring and evaluation may all have contributed to the failure to scale and spread most of the Vanguard models.

Conclusions: This programme is an example of the 'scale and spread paradox', in which localism was a key factor influencing the successful implementation of the Vanguards but ultimately limited their scale and spread.

Objective: State-level variation in how restrictive policies affect health care access for transgender populations has not been widely studied. Therefore, we assessed the association between structural stigma and four measures of individual health care access among transgender people in the United States, and the extent to which structural stigma explains state-level variability.

Methods: Data were drawn from the 2015-2019 Behavioral Risk Factor Surveillance System and the Human Rights Campaign's State Equality Index. We calculated weighted proportions and conducted multilevel logistic regression of individual heterogeneity and discriminatory accuracy.

Results: An increase in the structural stigma score by one standard deviation was associated with lower odds of health care coverage (OR = 0.80; 95% CI: 0.66, 0.96) after adjusting for individual-level confounders. Approximately 11% of the total variance for insurance coverage was attributable to the state level; however, only 18% of state-level variability was explained by structural stigma. Adding Medicaid expansion attenuated the structural stigma-insurance association and explained 22% of state-level variation in health insurance. For the remaining outcomes (usual source of care, routine medical check-up, and cost-related barriers), we found neither meaningful associations nor considerable between-state variability.

Conclusions: Our findings support the importance of Medicaid expansion and transgender-inclusive antidiscrimination protections to enhance health care insurance coverage. From a measurement perspective, however, additional research is needed to develop and validate measures of transgender-specific structural stigma to guide future policy interventions.

Objective: To explore how mental health trusts in England adapted and responded to the challenges posed by the COVID-19 pandemic, with the aim of identifying lessons that can be learned during and beyond the pandemic.

Methods: Following a scoping study, we undertook 52 semi-structured interviews with senior managers, clinicians, patient representatives and commissioning staff across four case study sites. These sites varied in size, location and grading awarded by a national regulatory body. We explored how services have been repurposed and reorganized in response to the pandemic and the participants' perceptions of the impact of these changes on quality of care and the wellbeing of staff.

Results: Mental health trusts have shown great flexibility and resilience in rapidly implementing new models of care and developing creative digital solutions at speed. New collaborative arrangements have been stimulated by a shared sense of urgency and enabled by additional funding and a more permissive policy environment. But there has also been a significant negative impact on the wellbeing of staff, particularly those staff from a minority ethnic background. Also, there were concerns that digital technology could effectively disenfranchise some vulnerable groups and exacerbate existing health inequalities.

Conclusions: Many of the service changes and digital innovations undertaken during the pandemic appear promising. Nevertheless, those changes need to be urgently and rigorously appraised to assure their effectiveness and to assess their impact on social exclusion and health inequalities.

Background: The impact of hospital building design on patients, families and nurses related to nursing care interactions is not well understood. This study reports a pre-post intervention study to understand the effects of the move to a new children's hospital in Perth, Australia, on nurse workflow activities and on patient, family, and nurse experiences.

Methods: We used a pre-post explanatory sequential design involving observation of nurse work tasks; measurement of the Practice Environment Scale and Nurse Work Index; weekly surveys of nurse, patient and family experiences; and nurse focus groups and interviews with patients and families. Survey data were analysed using linear regression; qualitative data analysis used a thematic approach.

Results: Nurse time spent walking almost doubled (p < 0.001), from an estimated 10 min at T1 (pre-move) to around 20 min at T4 (12 months post-move), but there was no difference in nurse time providing patient care (p = 0.114). The Practice Environment Scale and Nurse Work Index showed significantly reduced scores for nursing foundations for quality of care (adjusted mean difference -0.08, p = 0.016) and staffing and resource adequacy (adjusted mean difference -0.19, p < 0.001).This fall was mirrored in nurse experience surveys with a reduction in mean scores from T1 to T3 (3 months post-move) of -0.7 (p < 0.001) and from T1 to T4 of -0.4 (p = 0.002). Thematic analysis of qualitative data found that initial challenges appeared to reduce over time. Nurses reported difficulties managing workflow in the new wards and feelings of exhaustion at T3, but this changed to more positive accounts at T4. For patients and families there was a tension between leaving the old and familiar, enjoying the light and space of the new and shared observations that nurses appeared to be busier at T3. At T4, these experiences had changed to 'being a family in hospital' and confidence that a nurse was always close by.

Conclusions: Both benefits and challenges of the new hospital design were encountered from the perspective of nurses, patients, and families. Nurses spent double the time walking in the new environment, but time spent providing patient care was unchanged. Over time, the initial practice challenges reduced as nurses adapted to working in the new environment.

Trial registration: ACTRN12618000775213.

Objective: In 2017, the Australian state of New South Wales introduced a revised policy to provide a healthy food and drink environment for staff and visitors in the state's publicly funded health facilities. We sought to understand how contextual factors, intervention features and the responses of diverse stakeholders affected the policy's implementation in public hospitals.

Methods: Ninety-nine interviews were conducted with chief executives, implementers and retailers in the health and food retail systems after the target date for the implementation of 13 initial policy practices. Stakeholder responses were analysed to understand commitment to, engagement with and achievement of these practices and the different contexts and implementation approaches that prompted these responses.

Results: Key mechanisms that drove systemic change included stakeholders' broad acceptance of the policy premise; stakeholders' sense of accountability and desire for the policy to succeed; and the policy's perceived benefits, feasibility and effectiveness. Important underpinning factors were chief executives' commitment to implementation and monitoring, a flexible approach to locally tailored implementation and historical precedents.

Conclusions: This study provides policy and practice insights for the initial phase of state-wide implementation to achieve change in health facility food retail environments.

Objective: The barriers to delivering clinical non-communicable disease services in low- and middle-income countries have risen with the onset of COVID-19. Using Ghana as a case study, this article examines the changes COVID-19 has brought to diabetes service delivery and considers policy responses to deal with future such outbreaks.

Methods: We conducted 18 interviews between November 2020 and February 2021 with health professionals and administrators from primary, secondary and tertiary facilities within the Ghana Health Service. The analysis was performed using deductive and inductive methods.

Results: There were six general themes in interviewees' responses: (1) COVID-19 had exacerbated the problems of high medicine and service costs and medicine shortages, (2) the pandemic had exacerbated problems of poor patient record keeping, (3) COVID-19 had reduced the availability of suitably trained health providers, (4) staff had become demoralized by management's unwillingness to make innovative changes to cope with the pandemic, (5) COVID-19 led to a reorganization of diabetes services, and (6) the country's national health insurance scheme lacked flexibility in dealing with the pandemic.

Conclusions: Access to resources is limited in LMICs. However, our study highlights practical policy responses that can improve health providers' response to COVID-19 and future pandemics.

Objectives: Globally, there has been a shift towards integrated care delivery and patient-centredness in the design of health services. Such a transformation is underway in Ontario, which is progressively using an interprofessional team-based approach known as Ontario Health Teams (OHTs) to deliver care. During their initial development, OHTs were required to integrate patient and families' preferences, experiences and opinions in the form of consultation and partnership with patient and family advisors (PFAs). This study aimed to understand how PFAs were involved in the early stages of planning for health system change and the perceived benefits of including PFAs in system reform.

Methods: This study used a qualitative descriptive design. Semi-structured interviews were conducted with 126 participants at 12 OHTs, including PFA (n = 16) and non-PFA (n = 110) members (e.g. clinicians). Data were analysed thematically.

Results: We identified four themes; mechanisms of engagement, motivations to engage, challenges to PFA engagement and PFAs' impact and added value. Overall, participants viewed PFA engagement positively and PFAs felt valued and empowered. There remain logistical challenges around PFA compensation, and the amount of time and training expected of PFAs. However, all participants believed that developing an understanding of the patient, caregiver and family experience will strengthen the engagement of PFAs in OHT planning, decisions and policies.

Conclusions: Diverse approaches to and stages of PFA engagement fostered meaningful and highly valued contributions to OHT development. These were considered critical to successfully achieving the mandate of patient-centred care reform.

Objective: In 2020, the World Health Organization reported that immigrants were the most vulnerable to contracting COVID, due to a confluence of personal and structural barriers. This study explored how immigrants and refugees experienced access to health and social services during the first wave of COVID-19 in Toronto, Canada.

Methods: This study analyzed secondary data from a qualitative study that was conducted between May and September 2020 in Toronto that involved semi-structured interviews with 72 immigrants and refugees from 21 different countries. The secondary data analysis was informed by critical realism.

Results: The vast majority of participants experienced fear and anxiety during the COVID-19 outbreak but through a combination of self-reliance and community support came to terms with the realities of the pandemic. Some even found the lifestyle changes engendered by the pandemic a positive experience.

Conclusions: Self-reliance may hinder help-seeking and augment the threat of COVID-19. This is particularly a concern for the most vulnerable immigrants, who experience multiple disruptions in their health care, have limited material resources and social supports, and perhaps are still dealing with the challenges of settling in the new country.