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Shifting care into the community: Using Ostrom to explore collaborative care delivery with shared resources in English NHS Integrated Care Systems
Get PDFEnabling the delivery of efficient and effective healthcare services within a constrained financial environment is an enduring challenge. Shifting care from hospital to community settings is therefore a priority in many countries where it is hoped that they will reduce demand on hospital services and overall health system costs. In English Integrated Care Systems (ICSs) this is being done through new collaborative care processes involving community health services such as virtual wards. However, despite their critical role in integrated care, community health services have been relatively under-researched.
Using Ostrom’s theories of common pool resources, including principles for the use of finite resources for shared action, we examine whether ICSs in England can self-govern shared resources for collaborative services delivery. Drawing on the perspectives of community health services providers and ICS stakeholders who commission and manage them, we find a lack of proportional equivalence between costs and benefits for community health services providers. An enduring lack of visibility of community health services within the system suggest that the conditions for sustained collaboration between providers are not being met. This means that the policy intent for ICSs to facilitate more collaborative care and shift care from hospital to the community may not be realised
Perspectives on factors affecting disclosure and reporting of school violence in Zimbabwe
Get PDFBackground: Few recent studies in Zimbabwe focus on disclosure and reporting of violence against children. Qualitative studies grounded in children's experiences are particularly lacking. Understanding children's perspectives on why they choose to report violence or not, as well as adult perspectives, can encourage disclosure and ensure provision of services to children who experience violence.
Objective: We aimed to explore Zimbabwean primary-aged children's perspectives on factors affecting informal disclosure and formal reporting of school violence, and the barriers and enablers children face, alongside key perspectives from adults.
Participants and Setting: This study took place among children aged 8–12, parents, teachers and other key stakeholders in two Catholic primary schools within Harare (n = 94).
Methods: Qualitative data was collected in May 2022. Our methods included focus group discussions, interviews, observations and round robin workshops. We analysed transcripts thematically using Nvivo. Results: We find children are active agents in deciding about how, when and to whom they will informally disclose or formally report violence to, in some cases even choosing to protect those who receive disclosures. We find that not disclosing can also be an active choice. We also find there is heterogeneity in conceptualising disclosure and reporting, with children having different ideas about what merits reporting, and who violence should be reported to. The severity and frequency of violence may affect how they view certain types of violence being more worthy of reporting than others. Interestingly, boys’ views that girls enjoy certain abuses may also affect willingness to report or intervene.
Discussion: Our findings suggest the need for greater recognition of children's agency in deciding to report or not. More work should be done to understand and strengthen peer support, and train parents and others who receive disclosures. To increase disclosure, children's perceptions regarding which forms of violence warrant formal reporting should be challenged
The use of geographic information systems (GIS) in studying mental health service delivery: A scoping review.
Get PDFGeographic information systems (GIS) are computer-based spatial mapping tools widely used in public health to examine service availability and access disparities and healthcare utilization. While GIS has supported evidence-based health planning in various domains, its application in mental healthcare service delivery remains underexplored. Our scoping review aimed to address this gap by exploring the scope and type of GIS usage in studying three dimensions of mental health (MH) service delivery (availability, accessibility and utilization), across all geographical locations, settings and populations. We conducted a scoping review following the Joanna Briggs Institute methodology. We included peer-reviewed English-language studies using GIS to examine service delivery (availability, accessibility or utilization) for any MH condition diagnosed through standardized criteria or validated tools. Seven databases were searched (Medical Literature Analysis and Retrieval System Online [MEDLINE], PsycINFO, Excerpta Medica Database [Embase], Global Health, Cumulative Index to Nursing and Allied Health Literature [CINAHL], Cochrane Central Register of Controlled Trials [CENTRAL] and Web of Science) between January and April 2024. This review included 58 studies predominantly from high-income countries. A wide range of GIS methods were employed across studies, including hotspot analysis, network analysis and spatial analysis. Six studies explored availability, generally through measures like distribution of facilities across a population, and resource availability within 5-10-mile network buffers. Forty-six studies explored the spatial accessibility of MH services and substance-use treatment facilities using GIS. Six studies examined service utilization patterns. Equity emerged as a recurring theme across all three dimensions. GIS has the potential to emerge as a powerful tool in MH research, particularly in mapping disparities, informing service delivery and identifying high-risk zones. Expanding GIS use in trial design, implementation science and policy advocacy could help bridge critical gaps in MH service delivery, ensuring more equitable and data-driven decision-making
Rapid sequential mixed-method study to identify barriers and explore solutions for improving equitable access to community-based eye care services in Uttar Pradesh, India.
Get PDFOBJECTIVE: In low-income and middle-income countries, significant geographical and socioeconomic inequalities affect access to eye care. This study explores an equity-focused approach to improve access to eye care services provided by a community-based eye care organisation in northern India. DESIGN: A sequential exploratory mixed-method approach. SETTING: A high-volume eye screening programme in north Indian villages. Individuals identified with eye care needs during the screening were referred to the six nearby primary eye care centres. PARTICIPANTS: 7578 individuals identified with eye needs through a community-based eye screening programme. Of these, 4431 (58.6%) were women and 3137 (41.4%) were men.Socioeconomic questions, developed by experts and lay representatives, were integrated into an ongoing digitally supported (Peek Vision) eye screening programme in north Indian villages. Data from referred individuals identified with eye needs were analysed using logistic regression with a mixed-effect model to identify socioeconomic characteristics most strongly associated with poor access to care after referral. A sequential exploratory mixed-method approach, including in-person interviews and follow-up telephonic surveys of individuals with these characteristics, was used. OUTCOME: To identify barriers and gather suggestions for improving attendance from groups least likely to attend services. RESULTS: Of 7627 individuals referred for eye care, 7578 (99.3%) participated in the study. Of those, 2937 (38.5%) attended the Vision Centre, to which they were referred. The least likely to attend were individuals aged >16, those with dependents, and those referred for non-cataract conditions. Among the 3939 individuals with all three characteristics, the attendance rate was 35.3% compared with 42.5% (p<0.001) among the rest. Interviews with this group highlighted transport, personalised counselling, information dissemination, subsidised spectacles and village leader involvement as key suggestions. A telephonic survey with 400 individuals confirmed that the top priorities were free transport, personalised counselling and subsidised spectacles. CONCLUSION: Suggested programme improvements, including better counselling, reminder calls and transportation, could increase access among those least likely to access services after referral. This study demonstrates a two-step approach for identifying solutions from individuals facing the most significant barriers to care. We will go on to conduct trials of these suggested interventions
Kidney failure risk equation to predict kidney transplant failure in individuals with an eGFR<30 mL/min/1.73 m2: a UK Renal Registry external validation and recalibration study.
Get PDFOBJECTIVES: To externally validate and subsequently repurpose/recalibrate the easily accessible kidney failure risk equation (KFRE) for a prevalent transplant population with an estimated glomerular filtration rate (eGFR)<30 mL/min/1.73 m². It also aims to evaluate the recalibrated KFRE's potential to improve clinical practice with a clinical utility assessment. DESIGN: Retrospective cohort study using UK Renal Registry data. SETTING: 68 adult UK kidney centres. PARTICIPANTS: 4092 patients with grafts at least 2 years old and eGFR<30 mL/min/1.73 m2 from 2009 to 2018. PRIMARY OUTCOME MEASURE: Death-censored allograft failure at 2 years, defined as dialysis initiation, re-transplantation or, in the absence of the former two, the recorded date of transplant failure. PROGNOSTIC MODEL VALIDATION: The KFRE was calculated at baseline using the 2-year, 8-variable non-North American KFRE, and performance was assessed using Harrell's C-statistic and calibration plots. The model was recalibrated using Cox Regression (2009-2013 cohort) and temporally validated using the 2014-2018 cohort. Clinical utility was assessed using decision-curve analysis, estimating per-100-patient gains in timely planning and reductions in unnecessary interventions compared with eGFR triggers. RESULTS: The original KFRE had excellent discrimination but was miscalibrated, underpredicting graft failure. Temporal validation demonstrated that the performance of the recalibrated KFRE could be maintained across time periods (Harrell's C-index of 0.81 (95% CI 0.80 to 0.83); O/E (Observed/Expected events) ratio 1.00 (95% CI 0.93 to 1.07). It identified 9/100 more patients for timely intervention and 13/100 more for whom intervention could be delayed compared with a late clinical trigger of an eGFR<15 mL/min/1.73 m2. CONCLUSIONS: While there are other prognostic models, this is the first study to focus on the understudied and clinically important cohort of patients with an eGFR<30 mL/min/1.73 m², offering more relevant 2-year predictions. For this underserved population, we present an easily accessible model that is robust to temporal and case-mix differences, demonstrates clinical utility and has the potential to improve daily clinical practice
Short-term ambient heat exposure and low APGAR score in newborns: A time-stratified case-crossover analysis in São Paulo state, Brazil (2013-2019).
Get PDFExposure to high ambient temperatures near the time of delivery has been associated with adverse birth outcomes, but studies examining the impact on immediate newborn health remain limited. We used a time-stratified case-crossover design combined with a distributed lag nonlinear model to evaluate the short-term effects of ambient heat (0-1 day lag) on low 5-minute APGAR score (≤7; sub-categories: 6-7, 3-5, 0-2). Cases of low APGAR score among low-risk births (n = 34,980) in São Paulo state (274 municipalities), 2013-2019, were extracted from Brazil's Live Birth Information System (Sistema de Informações Sobre Nascidos Vivos). Municipality-level daily mean temperatures were constructed from ERA5-Land reanalysis data and linked with case and control days by date and municipality of delivery. Models were adjusted for relative humidity and stratified by maternal age, race/ethnicity, education, parity, timing of prenatal care initiation, infant sex, municipality-level deprivation, and Köppen climate zone. Overall, exposure to high (95th percentile: 26.1°C) versus moderate (50th percentile: 20.9°C) temperature 0-1 days before delivery was associated with 8% higher odds (OR: 1.08, 95% CI: 1.02-1.14) of low APGAR score (≤7). In stratified analyses, heat-associated risks were elevated among infants born to women with <12 years of schooling (1.10, 1.03-1.17) and/or self-identifying as Brown/Parda (1.10, 1.01-1.20). Associations were primarily driven by same-day (lag 0) exposure and were only observed in newborns with moderately low APGAR scores (6-7). Acute exposure to ambient heat may adversely impact newborns' immediate health in low-risk live-births, highlighting the need for heat mitigation measures near the time of delivery
Contribution and influence of social capital on corruption in the health sector: a view through the lens of service users.
Get PDFBACKGROUND: The interplay between social capital and health system corruption in healthcare systems is underexplored, yet vital, a major barrier to advancing universal health coverage is underexplored. While social capital can support anticorruption by enabling collective action, it may also perpetuate corruption when networks are used to bypass procedures or access care unfairly. This study explores how social capital contributes to corrupt practices complex relationships play out in practice in Nigerian health facilities. METHOD: We conducted a cross-sectional study across two Nigerian states, surveying 1659 households using a pretested interviewer-administered questionnaire. A composite measure of social capital was developed from key variables. We examined the relationship between social capital and engagement in corrupt practices, controlling for variables such as gender, age, education and group memberships. Data were analysed using univariate, bivariate and multivariate methods. RESULTS: Among respondents, 60.3% were female, over 90% had formal education, and 75.6% lived with their spouse. Nearly half (49.6%) had experienced corruption when accessing healthcare. Of those who used connections to receive care, 11.8% did so specifically to secure treatment. Individuals relying on family and friends (69.7%) were more likely to engage in corruption, and those using political connections always did. Non-membership in professional associations and political parties significantly reduced the likelihood of corrupt behaviour by 57% and 36%, respectively (p<0.01). Active participation in religious organisations was linked to lower corruption, while involvement in political parties, governance structures and professional bodies increased the likelihood. Higher education was associated with a 90% increased chance of engaging in corrupt practices (p<0.01). CONCLUSION: Social capital has both enabling and constraining effects on corruption in Nigeria's healthcare system. Understanding its context-specific nature is crucial for designing effective anti-corruption strategies in health service delivery
Network psychometric-based identification and structural analysis of a set of evolved human motives
Get PDFEstablishing a limited set of motives characteristic of the human species has been a goal in psychology since the beginning of the discipline. This paper uses a network-based analysis of previously published psychometric data to establish the existence of a pre-defined set of human motives. The set was derived by using evolutionary theory to identify what sorts of goals humans need to achieve to survive and reproduce in the niche our species evolved to fill. The analysis reported here is based on responses obtained from an on-line sample of 510 representative residents of the United Kingdom to 150 items. Analysis shows that all fifteen of the identified motives can be isolated, that they show expected relationships to one another (based on common functionality), and that differences in attentiveness to motives by gender reflect traditional gender-based role-play during human evolution, while differences by age are consistent with expectations from life history theory. The reduced set of 45 items identified by a genetic algorithm-based analysis could form the basis of a psychometric scale. Knowing the set of motives behind goal-directed behaviour should prove a significant boon to a wide variety of psychological applications, including human relations, educational strategies, marketing and behaviour change
Challenges in determining the global burden of non-malignant central nervous system tumors: An analysis of international incidence and mortality data sources.
Get PDFBACKGROUND: Non-malignant tumors of the CNS contribute substantially to the morbidity and mortality from CNS tumors. It is critical to understand the epidemiology of non-malignant CNS tumors separately from CNS malignancies to inform resource allocation and policy since treatment and prognosis can differ. High-quality international data on non-malignant CNS tumor burden are needed to accomplish this goal. METHODS: We assessed the cancer registry and vital registration data available to the Global Burden of Disease study by its inclusion of non-malignant CNS tumors, reporting on the availability of data over time and by the World Bank income group. We analyzed preliminary age-standardized incidence rates (ASIRs), age-standardized mortality rates (ASMRs), and proportions of CNS tumors by behavior for adults, children, and all ages. RESULTS: Non-malignant CNS tumors were reported separately in 17.2% (N = 66) of registry reports and in aggregate with malignant CNS tumors in 18.0% (N = 69) of reports. Only 7 low- and middle-income countries (LMICs) had data reporting CNS tumors separately by behavior. Across all ages combined, the median ASIR of non-malignant CNS tumor data was 0.31 (interquartile range: 0.15-0.50) and ASMR was 0.24 (0.10-0.44) per 100,000 in LMICs compared to median ASIR of 3.62 (2.62-4.97) and ASMR of 0.32 (0.16-0.65) in high-income countries (HICs). A larger proportion of incident CNS tumors were reported as non-malignant in HIC data than LMIC data (P < .0001). CONCLUSIONS: Our study alludes to current challenges in understanding global non-malignant CNS tumor burden and a need for increased international data collection. Further research is needed to comprehensively investigate opportunities for future data inclusion
Trabecular bone deficits predominate in the appendicular skeleton of midlife women living with HIV: findings from a cross-sectional study in Zimbabwe.
Get PDFHIV-related mortality has fallen due to the scale-up of antiretroviral therapy (ART), so more women living with HIV (WLH) now live to reach menopause. Menopausal estrogen loss causes bone loss, as do HIV and certain ART regimens. However, quantitative bone data from WLH are few in Africa. A cross-sectional study of women aged 40-60 yr (49% WLH) was conducted in Harare, Zimbabwe. Menopause status, fracture history, HIV status and treatment, and anthropometry were collected, and radial/tibial peripheral QCT (pQCT) scans were performed. pQCT outcomes were distal radius and tibia trabecular volumetric BMD (vBMD), total area, and compressive bone strength (BSIc); proximal radius and tibia cortical vBMD, BMC, cortical thickness, bone area, and stress-strain index (SSI). Linear regression determined differences by HIV status, minimally adjusted for age and menopause status, and further adjusted for height and fat mass. Relationships between pQCT parameters and major osteoporotic fracture history were explored using univariate logistic regression. In WLH, linear regression assessed associations between HIV and ART durations on pQCT measures. 384 women mean (SD) age 49.7 (5.8) yr had pQCT data. WLH had lower absolute pQCT measures at all sites. Overall, HIV-related deficits were robust to adjustment for age, menopause status, height, and fat mass: WLH had lower trabecular vBMD (radius -7.3 [-12.5; -2.0]%, tibia -5.4 [-9.1; -1.7]%), and cortical vBMD (radius -3.5 [-5.9; -1.1]%, tibia -1.1 [-1.6; -0.5]%). Strength estimates were lower in WLH and of similar magnitude at the radius and tibia. Longer HIV duration was associated with lower radius bone area, BMC, and estimates of bone strength, independent of ART duration. Trabecular deficits predominate in WLH, though with age cortical compartment bone loss may increase in importance. This is particularly concerning as these differences were observed at the radius, a common site of postmenopausal osteoporotic fracture