Frontiers in health services最新文献

Vision health is a critical yet often overlooked component of comprehensive primary care, particularly for underserved populations. Patient access to eye care services enhances workplace productivity, household income, and employment opportunities, ultimately supporting economic growth, poverty reduction, and food security. Community Health Centers (CHC) collectively serve over 32 million patients annually and are uniquely positioned to address disparities in eye care access. Yet only 26% of CHCs offer vision care services, and only 2.9% of people who access CHC services receive eye care. Addressing this gap requires a strategic, systems-level approach to implementation. This perspective proposes an integrated framework to guide the sustainable and equitable integration of eye care providers, including optometrists and ophthalmologists, into Community Health Centers (CHCs). Drawing on and uniting the Consolidated Framework for Implementation Research (CFIR), the National Institute on Minority Health and Health Disparities (NIMHD) Research Framework, and the National Association of Community Health Centers' (NACHC) Value Transformation Framework (VTF), we outline a multi-level strategy that addresses implementation readiness, equity, and sustainability. This integrated framework is intended to inform implementation research and policy development aimed at making on-site eye care via an optometrist or ophthalmologist a mandated service in CHCs nationwide. In doing so, we offer an actionable game plan for CHC leaders, healthcare administrators, and public health advocates to expand access to comprehensive eye care in underserved communities.

In Jordan, a Low- Middle-Income Country (LMIC) in the Eastern Mediterranean Region (EMR), tobacco use rates are among the highest globally. These alarming rates impose a huge economic and health burden and are exacerbated by cultural norms, societal misperceptions, and insufficient policy implementation. The tobacco epidemic is a multidimensional and complex one requiring multiple complementary solutions. One such solution is the availing of tobacco dependence treatment (TDT) services. However, establishing and maintaining TDT services can be challenging in resource-challenged countries. In this Policy and Practice Paper, we conducted a comprehensive critical analysis of Jordan's experience in initiating, expanding and maintaining TDT services, with the intention of providing insight which other LMICs seeking to establish TDT services can find useful. Our analysis is guided by the Consolidated Framework for Implementation Research (CFIR). Specifically, information was collected through both a desk review of the available evidence, and through expert insight from six healthcare practitioners directly involved in the establishment and/or implementation of TDT in Jordan. A CFIR assessment template was used to document the evidence and gather expert insights across the five CFIR domains (Innovation Domain, Outer Setting, Inner Setting, Individuals Domain, and Implementation Process Domain). Lessons learned and recommendations also were generated within each CFIR domain. Our findings, while presented in the context of Jordan as an LMIC, can be of use to other countries and settings with similar limited resources that will need to consider the adaptability and complexity of TDT, the broader policy and environmental setting within which TDT will be established, the physical and practice settings hosting TDT services, the potential stakeholders to engage in TDT establishment, and the changing implementation challenges faced when sustaining TDT services in an LMIC. Thus, our review can assist resource-limited countries planning or preparing to implement TDT services.

Background: Adaptive implementation strategies tailor support to setting needs rather than applying a uniform approach. These strategies improve efficiency and fit, yet practical guidance on identifying decision points and tailoring variables is limited. This study collected end-user and partner input to specify decision points and tailoring variables for an adaptive implementation strategy.

Methods: This study focused on the evidence-based nutrition program, Together, We Inspire Smart Eating (WISE). End users and implementation partners with prior experience in WISE were recruited in two states to participate in semi-structured interviews or focus groups designed to elicit feedback to specify an adaptive implementation strategy for WISE.

Results: Qualitative input supported three crucial decisions for an adaptive implementation strategy: (1) low-intensity support, the starting point for all sites, will include leadership commitments, local champions, an implementation blueprint, classroom reminders, and task-focused facilitation at the site level; (2) assessment of response to low-intensity support will occur in October (Month 3) of the school year; and (3) sites not responding by Month 3 will receive holistic facilitation and tailored educational materials at the teacher level. Participants emphasized the universal need for facilitation at all sites, with struggling sites requiring more. They also identified tailoring variables: sites with fewer than 60% of classrooms achieving fidelity would require high-intensity support.

Conclusions: This study illustrates a process for using feedback from end users and partners to define key elements of an adaptive implementation strategy. Our approach holds significant potential to specify strategies for scaling health-related evidence.

Background: Appropriate communication with patients is increasingly crucial in a growing elderly population to prevent both over- and undertreatment. Advance care planning (ACP) is recognized as a valuable communication process for patients, their relatives and healthcare professionals that facilitates future care and medical decision-making. Despite its importance, the uptake remains low, particularly among frail, older patients in hospitals.

Methods: This qualitative substudy is nested within a cluster randomized controlled trial. Data collection involved eight semi-structured interviews conducted in acute geriatric hospital units receiving our implementation support program, along with informal data from interactions with the units during the implementation process. The aim was to explore healthcare professionals' perspectives on the barriers and facilitators to ACP implementation and their experiences with the implementation support program. A semi-structured interview guide was used. The data was analyzed using content analysis.

Results: Factors influencing ACP implementation were identified at three levels: a) the organizational level, b) the national level, and c) the clinical level. Participants recognized the critical role of timing, context, and patients' capacity. However, there was meaningful opportunities for ACP conversations in acute geriatric units. Overall, the experiences underscored the complex interplay of individual motivation and interest, organizational support, prioritization, available time and resources, and systemic factors that influence the integration of ACP into clinical practice, as well as the fact that research can act as both a barrier and a facilitator in implementation efforts.

Discussion: This study illustrates the significant challenges in implementing ACP in acute hospital care. Despite a generally positive perception of ACP, its implementation was hindered by barriers such as overwhelming workload, production-oriented healthcare, the biomedical model, and lack of prioritization. These factors creates a cycle where short-term demands overshadow preventive and patient-centered interventions, limiting their perceived and documented benefits. Breaking this cycle will likely require targeted investment in the implementation of complex interventions.

Trial registration: ClinicalTrials.gov, Identifier NCT05681585.

Objective: This study provides the first empirical evaluation of Taiwan's Hospital-at-Home (HaH) pilot program, launched in 2024 under the National Health Insurance system. The aim was to examine the clinical effectiveness, safety, and economic feasibility of HaH in managing acute infections, including pneumonia, urinary tract infections (UTIs), and soft tissue infections (STIs), among older adults living in long-term care facilities.

Methods: A prospective, matched-controlled study was conducted from July 2024 to June 2025 across seven nursing homes. Sixty residents aged 65 years or older who received HaH care were matched in a 1:2 ratio with 120 hospitalized patients by age, sex, and diagnosis. HaH services were delivered by a single interdisciplinary team. Primary outcomes included care duration, medical costs (USD), emergency department (ED) revisits, readmissions, and mortality. Secondary outcomes were complication rates. Statistical analyses used Chi-square tests, t-tests, and Mann-Whitney U tests, with odds ratios and 95% confidence intervals reported. A p-value < 0.05 was considered significant.

Results: HaH patients had significantly shorter care episodes compared with hospitalized patients (6.6 ± 1.5 vs. 11.8 ± 6.0 days, p < 0.001) and lower medical costs across all diagnoses. For STIs, costs were reduced by 65.1% (USD 979 vs. 2,805, p < 0.001), while UTIs and pneumonia showed savings of 46.0% and 45.5%, respectively. Overall clinical outcomes, including ED revisits, readmissions, and mortality, were similar between groups. In the STI subgroup, HaH patients had a significantly lower 14-day ED revisit rate (7.4% vs. 27.8%, odds ratio 0.21, 95% confidence interval 0.04-0.99, p = 0.04). HaH patients also experienced fewer hospital-acquired complications, particularly gastrointestinal and neurological events.

Conclusion: The findings demonstrate that HaH is a safe, effective, and cost-efficient alternative to hospitalization for acute infections in institutionalized older adults. By reducing care duration and costs without compromising clinical outcomes, HaH offers a patient-centered model that can ease healthcare system pressures in rapidly aging societies. These results support further expansion of HaH in Taiwan and encourage additional longitudinal studies to confirm long-term benefits and broader health system impacts.

Background: A significant proportion of patients with chronic obstructive pulmonary disease (COPD) continue smoking after diagnosis, contributing to increased symptom burden, more frequent exacerbations and poorer long-term outcomes. Hospitalisation due to COPD exacerbation may serve as a "window of opportunity" for delivering smoking cessation support.

Aim: This pilot study evaluated the feasibility of integrating structured smoking cessation support into routine inpatient care for patients hospitalised with a COPD exacerbation.

Methods: We followed 45 patients admitted for COPD exacerbation who reported active smoking at baseline. Smoking status and COPD symptoms (COPD Assessment Test, CAT) were evaluated at baseline, 1 month and 3 months after discharge. Comparisons were made between participants with smoking and non-smoking status at 1 month follow-up, and across three groups at 3 months: sustained non-smoking, sustained smoking and smoking relapse.

Results: At 1 month, 30 patients (66.7%) reported abstinence, and 19 (42.2%) remained abstinent at 3 months. Improvements in mean CAT scores were observed over time, from 22.9 (95% CI = 20.0-25.7) at baseline to 13.9 (CI = 11.4-16.3) at 1 month and 12.9 (CI = 10.1-15.6) at 3 months. A trend towards lower CAT scores were observed for participants with non-smoking status at follow-up, compared with those who were smoking. We observed, that those who sustained non-smoking at follow-up were older, had higher baseline expectations of quitting and reported greater confidence in their ability to stop. However, those who relapsed at three months were the oldest. Being without a partner appeared more common among sustained smoking at follow-up.

Conclusion: Smoking cessation support initiated during COPD hospitalisation was feasible and the majority of patients reported short-term abstinence and meaningful reductions in symptom burden. Age, expectations and confidence appeared to affect cessation trajectories, but should be explored further in larger, controlled trials and implementation setups.

Background: Evidence-based practice means making decisions based on evidence which takes account of experiences, values and preferences of employees and users. Fragmentation of services, technological limitations, lack of workforce, cultural resistance, resource constraints and distance between academia and practice can make the utilisation of evidence in health and social care services challenging. This study aimed to provide new insights into the development and implementation of a model for research support for decision-makers in municipal healthcare.

Methods: We used a qualitative design to explore stakeholders' experiences with development and implementation of the model for research support. We included minutes from several meetings and evaluation forms from the participating municipalities, ranging from the start of the project in January 2021 to the end of the project in January 2024. We conducted a thematic analysis, and the textual data were coded into categories and mapped according to the constructs of the consolidated framework for implementation (CFIR).

Results: The stakeholders in the municipalities expressed need for a support model to apply research in prioritising, planning and decision making. There were barriers to implementing the model due to complex and broad research questions. The researchers needed to navigate between methodological thoroughness and practical usability. The participants from the municipalities reported lack of structure, funding, competence and incentives to apply the evidence. They also struggled with dissemination and implementation of the results from the research summaries. Facilitating factors were political and administrative commitment, availability of research findings in plain language, a learning-by-doing approach through meetings and seminars working on real-world municipal challenges, and a structured collaboration between municipality employees and academics.

Conclusions: The study indicates that research support for decision-makers in the application of systematic reviews can be useful for evidence-based decision-making in municipal healthcare. However, implementing the model is resource-demanding, considering the use of time and personnel, both from the municipalities' and research institutions' point of view. Future research is needed to assess the effectiveness of the research-based support model towards better decision-making in municipalities and improvedpatient care.

Background: Mental health services are operating under significant and sustained pressures. Healthcare professionals and managers are continually making adjustments, often improvised and inconsistent across teams. This study aimed to identify and describe the everyday pressures experienced in community mental health settings and the adaptive strategies used by senior leadership and management staff to respond. The longer-term goal is to inform more coordinated, practical approaches to managing services under pressure.

Methods: We conducted qualitative semi-structured interviews with 22 senior leadership and management staff from community mental health services within a single NHS Trust in England. Interviews explored the everyday pressures encountered and the strategies adopted in response. Data were analysed thematically using a template analysis approach, guided by our previously developed framework-a taxonomy of pressures and adaptive strategies from earlier studies in surgery and intensive care.

Results: The main source of pressure was a shortage of staff with the necessary skills and experience to manage increasing patient numbers and complexity. Strategies were categorised as anticipatory (implemented in advance of expected pressures) and on-the-day responses. Most were anticipatory, reflecting limited capacity for real-time adaptation. Common strategies involved controlling patient demand and prioritising urgent cases, flexing staff allocation, and enhancing staff support, supervision, and coordination. Flexible use of external services, such as primary care and voluntary sector resources, was also reported.

Conclusions: Senior mental health staff employ a broad range of adaptive strategies during periods of pressure to manage patient risk, sustain patient flow, and support staff wellbeing. Compared with acute hospital settings such as surgery and intensive care, anticipatory strategies were more prevalent in mental health services, where day-to-day flexibility is constrained by staffing and service structures. There is significant potential to train clinical leaders and teams in the effective use of adaptive strategies and to improve cross-service coordination. The framework used in this study offers a shared language and a practical menu of options to help mental health services prioritise rising patient demand and safeguard staff wellbeing.

Introduction: Over half of the children and youth with mental illness do not receive appropriate or adequate treatment in both Canada and the United States. The burden of mental illness and substance use is the leading cause of disability due to years lost to disability, leading to the youth mental health crisis. Despite ongoing efforts to improve mental health and substance use services, many youth disengage prematurely, with evidence that this leads to poorer outcomes. In this paper, we explore the question: how to use youth-friendly methods in research for service improvement.

Methods: We used innovative and participatory action mixed methods. Youth between the ages of 12 and 25, with lived experience accessing mental health and addiction services, were recruited for focus groups. The focus groups were stratified based on their level of service needs, and data were analyzed using thematic analysis. The themes were interpreted into a fictional narrative summarized in an animated video. This video was embedded in a survey that was sent to the participants. The purpose was to validate the analysis and explore the factors that led them to participate. A descriptive analysis of the quantitative data and an inductive content analysis of the qualitative data were completed for the survey.

Results: A total of 44 youth completed the screening to stratify the level of need. Fourteen youth participated in three pilot focus groups, and another 24 participated in four focus groups stratified by need. The mean age was 22.3 years, and 78% and 22% identified as male and female, respectively. Youth-friendly research was the main theme, with two main sub-themes: youth want to participate in research, and there were strategies for research approaches involving youth service users. Fundamentally, choice throughout the process was important.

Conclusion: Youth service users want to be engaged meaningfully. Youth are not afraid to speak their truth and want opportunities to provide their unique perspectives. Service improvements from youth service-user feedback may lead to improved outcomes with full treatment because youth remain engaged with services. Service improvement may need youth-friendly research.

Community Health Workers (CHWs) are central to extending primary health care in low-resource settings, yet their compensation remains a policy challenge. This paper reports findings from a five-arm quasi-experimental study conducted by Living Goods Uganda to test how different mixes of fixed stipends and performance-based incentives (PBIs) affect CHW performance, motivation, and retention. Over a nine-month period, 1,104 CHWs were assigned to five compensation models-70:30, 50:50, 30:70 PBI-to-stipend ratios, a 100% stipend arm, and a control-implemented across five districts. Quantitative data were analyzed using a difference-in-differences model with cluster-robust standard errors and wild-bootstrap inference, complemented by qualitative interviews and focus groups exploring experiences and perceptions. Results showed that moderate performance-based incentives (30%-50%) achieved the most balanced outcomes: improved household coverage, immunization follow-up, and referrals, alongside higher motivation and satisfaction. The 70% PBI arm generated stronger performance gains but increased stress and reduced retention, while the stipend-only arm offered stability but lower service coverage. Overall retention exceeded 95%, though sustained motivation depended heavily on supervision quality, recognition, and fairness of pay. Findings highlight that hybrid pay structures combining predictable stipends with moderate PBIs can enhance CHW productivity while safeguarding motivation and sustainability. The study offers practical guidance for Uganda's National Community Health Strategy and similar programs seeking equitable, gender-sensitive, and financially feasible CHW compensation models.