1,720,984 research outputs found
Haiti’s community-based ART distribution strategy and its role in supporting patient retention
No full textThesis (Master's)--University of Washington, 2019Haiti developed a community-based ART distribution strategy (by its French acronym, “DAC”) to reduce barriers to active ART participation and adherence. Patients who are stable on ART after the first six months of treatment are eligible for DAC. For patients interested in receiving ART in the community, health care staff distribute medications in the patient’s home or at other agreed locations determined by the patient. We sought to evaluate the scale-up of the DAC approach and assess the relationship between DAC participation and active ART participation. In this mixed-methods descriptive study, we used secondary data on medication dispenses from 92 health facilities participating in Haiti’s national-level electronic medical record system, iSanté. The data source covered person-level data on ART prescriptions from 92 health facilities, from January 2017 through March 2018. We examined documentation of DAC participation via pharmacy encounter forms, assessed patient, facility, and health network factors associated with DAC, and described outcomes of active ART participation among DAC and non-DAC patients. We purposively sampled 8 facilities with greater and lesser documented use of DAC from two health networks, interviewing two key informants from each, to identify practices and challenges in implementing DAC and monitoring patient outcomes. Seventy-three facilities (79.3%) documented at least one DAC dispense, and 57 facilities that documented DAC (78.1%) showed reliable DAC documentation from January 2017 to March 2018. 18.0% of patients at the 92 facilities had at least once dispense delivered through DAC from January 2017 to March 2018, compared to 23.8% of patients at the 57 reliable DAC facilities. After adjusting for covariates, patients with a DAC dispense had an odds of being actively retained on ART following a dispense which was 16% lower compared to patients whose ART was dispensed in the clinic. We conclude that the DAC approach has scaled up in a variable way across health facilities. Documentation of the DAC approach within the national electronic medical record system could be improved
Going Beyond Counting First Authors in Author Co-citation Analysis
Full text linkThe present study examines one of the fundamental aspects of author co-citation analysis (ACA) - the way co-citation
counts are defined. Co-citation counting provides the data on which all subsequent statistical analyses and mappings
are based, and we compare ACA results based on two different types of co-citation counting - the traditional type that
only counts the first one among a cited work's authors on the one hand and a non-traditional type that takes into
account the first 5 authors of a cited work on the other hand. Results indicate that the picture produced through this non-traditional author co-citation counting contains more coherent author groups and is therefore considerably clearer. However, this picture represents fewer specialties in the research field being studied than that produced through the traditional first-author co-citation counting when the same number of top-ranked authors is selected and analyzed. Reasons for these effects are discussed
An Outcome Evaluation of the Health Information Management and Applied Epidemiology (HIMAE) course in South Africa
No full textThesis (Master's)--University of Washington, 2019Background: Health Information Systems (HIS) can provide accurate and reliable data for patient monitoring, disease surveillance, program evaluation, and resource allocation at varying levels of a national health system. South Africa has been making poor progress on meeting targets for HIV epidemic control due to a lack of data capturers at the facility-level and poor data quality. Blended learning has been identified as one feasible option to address this gap. This paper evaluates the Health Information Management and Applied Epidemiology (HIMAE) course designed to train frontline healthcare workers in South Africa. Methods: The ten module HIMAE course was disseminated through a Demonstration Programme (DP) and Open Choice Programme (OCP). Participants had access to e-learning, USB, and workbook modalities. Pre- and post-test scores were used to evaluate change in knowledge over the first five modules of the course which was defined as course completion. Completer and non-completer interviews were conducted to assess participant attitudes towards course delivery and uptake and measure translation into daily practice. Descriptive statistics, t-tests, and linear regressions were calculated to determine differences within and across dissemination groups. Interviews were coded and analyzed for common themes based on findings from the quantitative analysis. Results: A total of 331 participants took part in the study. 39 participants were enrolled in the DP and 292 were enrolled in the OCP. DP participants were 3.9 (95% CI: 2.2-6.7, p <0.001) times more likely to complete the first five modules than those in the OCP. On average, DP participants’ test-scores improved by 24.2 percentage-points and the OCP improved by 21.0 percentage-points. There were no significant differences in mean post-test scores across dissemination groups or mean score differences among cadres. The DP model increased motivation to complete the course but did not change the types of uptake barriers faced by participants. Conclusion: Overall, the course significantly improved participant knowledge in data literacy. Interview participants also indicated several ways they applied knowledge gained from the course into their daily practice. Based on these findings, the HIMAE course can provide an approach to remove barriers of poor data quality and large frontline health worker knowledge gaps as well as assist South Africa to make improved progress to meeting targets for HIV control
Social determinants of health and interruption in treatment outcomes within Haiti’s electronic medical record system for people living with HIV
No full textThesis (Master's)--University of Washington, 2023Haiti has made significant progress in reducing the national burden of HIV, however patient retention in care and treatment persists as a key challenge. Low-resource settings are increasingly using electronic medical records (EMRs) to strengthen their health information systems and improve patient outcomes. Social determinants of health (SDOH) like employment, education, food insecurity, and stigma are documented risk factors for poor HIV treatment outcomes but are often not captured or collected in structured formats in EMRs. We conducted an exploratory study assessing the types and completeness of SDOH data in Haiti’s EMR and investigated associations with interruption in treatment (IIT) at 6- and 12-months post-antiretroviral therapy (ART) initiation. We used patient-level data from 51 clinic sites. Eligible patients were adults with a documented ART start date between July 2016 and January 2022. SDOH variables were categorized by the following six domains: 1) economic stability, 2) education, 3) food, 4) social and community context, 5) physical and built environment, and 6) health and clinical care. A mixed effects logistic regression model was fit to assess the relationship between independent SDOH variables and IIT. We found a lack of variables related to physical and built environment, food, education, and economic stability in Haiti’s EMR. Data completion varied by variable type for several SDOH variables available for analysis. Approximately one in ten patients had IIT at 6 months and nearly one in five had IIT at 12 months. Documentation of the HIV status of other household members, a possible marker for social context, was associated with a lower likelihood of IIT. There were several SDOH reasons associated with higher risk of IIT, including travel and lack of food. This analysis highlights a missed opportunity to collect individual-level SDOH data within Haiti’s EMR and identify clients at greatest risk of IIT who could benefit from interventions to provide enhanced support for ART retention in care
The Quality in Health Information Systems Study: Perceptions of the quality of digital health information systems in the global health domain.
Full text linkThesis (Master's)--University of Washington, 2023This study explores the diverse perspectives of stakeholders on the definition and concerns surrounding the quality of electronic medical records (EMRs). Furthermore, it illustrates how the EMR quality aspects can be mapped into the STEEEP framework. Several trends emerged, including a heightened concern for clinical decision support and data quality by EMR builders and implementers, a high focus on stakeholder engagement and capacity building for decision makers, and a strong focus on technical aspects of EMRs for domain experts. Effectiveness and efficiency were identified as key domains, focusing on clinical decision support, data availability and quality, and meeting functional requirements. It was noted that interoperability and data exchange were emphasized across a number of domains, while patient-centeredness and equity were given relatively less attention. Quality assessment and implementation were also identified as critical factors, emphasizing the importance of stakeholder engagement and planning. The study made several recommendations, including the need for user-centered EMR design, standard data sharing, and further investigation of equity issues
Usability and acceptability of electronic immunization registry (EIR) data-entry workflows from the healthcare worker perspective in Siaya, Kenya
No full textThesis (Master's)--University of Washington, 2020Introduction: Digital health tools such as electronic immunization registries (EIRs) have the potential to improve patient care and alleviate challenges that arise from the use of paper-based clinic records for reporting. To address some of these challenges, the Kenya Ministry of Health (MOH) and the International Training and Education Centre for Health in Kenya (I-TECH-Kenya) implemented an EIR system in all 161 of Siaya county’s immunizing clinics between 2018 – 2019. Successful implementation of digital health tools depends on many factors, one of which is alignment between the technology and the context in which it is used. One important aspect of that implementation context is the perceptions of the healthcare workers (HCWs) using the EIR. Without full adoption of the EIR by HCWs into their clinic workflow, many of the potential benefits of the EIR cannot be realized. This study evaluates HCW perceptions of usability and acceptability of multiple clinic workflows using the new EIR. Methods: We performed a mixed-methods pre-post study using semi-structured interviews of healthcare workers at 6 facilities in Gem sub-county of Siaya county, Kenya. We interviewed HCWs at each facility 4 times: at baseline and once after implementation of each of three different workflow modifications (n=24 interviews). The interviews used a combination of open-ended interview questions and scale-based indicators based on the NASA Task Load Index and usability heuristics. The baseline state involved dual data-entry with paper records and the EIR. We implemented the three workflow modifications for one full day each: fully paperless data entry, preparation of an appointment diary prior to the day’s patient visits began, and a combination of paperless plus preparation workflows together. We compared aggregate scores from the indicators and interview themes across each of the four workflows in order to understand changes in usability and acceptability of the EIR. Results: We found that, overall, the EIR clinic workflows were considered usable and acceptable by the HCWs. Of the modified workflows, we found the HCWs perceived the fully paperless workflow to be the most favorable, while the baseline, preparation, and combined workflows had mixed results. In all workflows, benefits perceived by the HCWs included ease of clinical decision-making using the EIR, reduced mental burden of the data entry when using the EIR, and ease of identification of errors. Challenges perceived by the HCWs regarding workflow acceptability included contextual challenges such as staffing shortages and lack of network connectivity, EIR platform challenges such as errors saving records and missing fields, and workflow challenges such as the dual data entry burden of paper and digital tools. Conclusion: Fully paperless EIR implementation shows great promise from a workflow acceptability standpoint, contingent upon presence of supporting contextual clinic factors and resolution of system performance and design challenges. An acceptable EIR will provide adequate flexibility for HCWs to implement the new system in their unique clinic context. Rather than trying to identify a singular best workflow, future efforts to optimize EIR implementation should look for ways to maximize flexibility, reliability of the app, and strong enabling environments, and let the HCWs in each clinic match the EIR to their real-world context to have the best results for data use
The Use of Electronic Medical Records and Clinical Decision Support Tools to Evaluate and Strengthen HIV Care in Haiti and Ukraine
Full text linkThesis (Ph.D.)--University of Washington, 2023Use of electronic medical records (EMRs) and clinical decision support (CDS) tools to support HIV care has been growing in low- and middle-income countries. Data from these systems can inform incidence surveillance, index partner tracing, HIV program evaluation, and individual patient care. However, there are several barriers to the use of this data for decision making, including negative perceptions of the usefulness and trustworthiness of routine data, data quality issues, and limitations of observational data for causal inference in program and policy evaluation. Our objective was to better understand how EMRs and CDS tools could be leveraged to strengthen and support HIV care in Haiti and Ukraine, including understanding barriers and facilitators to tool use, associations between EMR data quality and patient outcomes, and use of quasi-experimental methodology to evaluate public health interventions (here, index testing and partner services). Related to each of these questions, we found that: 1) providers had generally positive views of EMR-informed CDS tools, particularly their potential to improve decision-making and patient outcomes; 2) that EMR data missingness is associated with poorer retention in care, particularly among children living with HIV, suggesting that data quality is a crucial element of clinical case management and quality of care; 3) and that EMR data can enable large-scale analyses of effectiveness of public health interventions, and specifically in this case example, showing evidence of index testing program effectiveness at brining named partners into HIV care and treatment at earlier stages of HIV disease progression
PrEP Persistence Among Key Populations in Ukraine: Analysis of Scaled PrEP Program Data from October 2020 through February 2022
No full textThesis (Master's)--University of Washington, 2023BackgroundWhile global HIV incidence has rapidly decreased during the last decade, Central and Eastern Europe have experienced a significant rise in new cases annually. Ukraine, located in Eastern Europe, has been one of the most ambitious in the region in implementing programs to combat HIV since 2017, including expanding access to PrEP among key populations starting in 2020. Little is known about persistence on PrEP in subpopulations accessing it in Ukraine.
Methods
Ukraine’s PrEP program was implemented in 40 health care facilities in 11 high-burden regions in Ukraine. We analyzed data from program initiation on October 1, 2020 through February 23, 2022. A Sankey diagram was constructed to visualize times between the first four PrEP visits. We conducted a Kaplan-Meier analysis to estimate persistence time for each key group, stratifying by men who have sex with men (MSM), people who inject drugs (PWID), sex workers (SW), and discordant couples and other people vulnerable to HIV acquisition (DC/Other). We also evaluated whether persistence varied by sex and age using the Kaplan-Meier method. We used a Cox regression, clustering by healthcare facility, to estimate hazard ratios for non-persistence by key group and sex, and adjust for age as a potential confounding factor.
Results
There were 2,033 clients newly starting PrEP with up to 510 days of observation. 65% of clients were males, with a median age of 35 years [IQR=29-42] and 35% were females with a median age of 37 years [IQR=31-43]. There were 51% DC/Other, 22% MSM, 22% PWID and 5% SW. The number of days between visits varied across clients and visit timepoints. Among clients returning to collect a 2nd PrEP prescription, 81% returned within 1-45 days after their previous visit, and 3% discontinued PrEP and then re-initiated after 106 days or more. Six-month persistence estimates were highest overall among PWID (28.9%; 95% CI: 23.4-35.7%), moderate in comparison among SW (18.5%; 95% CI: 11.1-30.8%) and DC/Other (12.7%; 95% CI: 10.0-16.0%), and dropped to nearly 0 among MSM (0.8%; 95% CI: 0.1-5.8%). Individuals aged 26 and above were slightly more likely to persist on PrEP longer than younger individuals and females were slightly more likely to persist on PrEP than males. PrEP persistence calculated using the Kaplan-Meier method differed significantly by key group and age (p<0.05), but not by sex. In the Cox regression model, compared with the female DC/Other reference group and adjusted for age, female PWID had the lowest risk of PrEP discontinuation (adjusted HR [aHR] 0.59; 95% CI: 0.31-1.11) while male SW had the highest discontinuation risk (aHR 1.87, 95% CI: 0.57-6.11), although findings were not statistically significant.
Conclusion
PrEP persistence at 6 months was low with the majority of individuals discontinuing PrEP by 6 months. Further research examining barriers and facilitators of persistence by groups can inform interventions to increase PrEP persistence
Transitioning from paper to digital vaccination records: integration into clinic workflows, time utilization following workflow modifications, and impact on the timeliness of vaccinations
No full textThesis (Ph.D.)--University of Washington, 2020Digital health interventions (DHI) have the potential to improve the management and utilization of health information to optimize healthcare worker performance and provision of care. Especially in Africa, where 25% of children remain un- or under-immunized, technologies that can help identify children due for a vaccination are particularly important for improving vaccination coverage. Low- and middle-income countries (LMICs) are beginning to introduce electronic immunization registries (EIRs) into their routine immunization services to better capture and store childhood vaccination information. Despite the increased introduction of EIRs in LMICs, few have been institutionalized at scale or evaluated to understand their impact on health systems and health-related outcomes. An improved understanding of the usability and effectiveness of these systems is needed to inform strategies for developing, deploying, and sustaining EIRs. We used qualitative data from semi-structured interviews with healthcare workers, time-and-motion observations of user workflows, and EIR data to study the effects of introducing an EIR on healthcare workers and vaccination-outcomes. The specific dissertation aims included: 1) describing the integration of an EIR into immunization clinic workflows in Kenya using realist methodology; 2) comparing time utilization of modified user workflows among immunization clinics in Kenya using an EIR; and, 3) assessing changes in on-time vaccination following the introduction of an EIR in Tanzania. We found that although EIRs were well accepted by users, there was often misalignment in goals and workflows between the system and reality which created challenges to EIR-use, increasing the time spent on data management activities, and ultimately, reducing the quality of EIR records, making them inadequate for measuring health-related outcomes at the population-level. Our research provided evidence on the importance of designing and deploying EIRs that closely align with user-workflows to increase the potential added value of these systems for improving provision of healthcare services and immunization coverage
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