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Background: The application of adaptive design methodology within a clinical trial setting is becoming increasingly popular. However the application of these methods within trials is not being reported as adaptive designs hence making it more difficult to capture the emerging use of these designs. Within this review, we aim to understand how adaptive design methodology is being reported, whether these methods are explicitly stated as an 'adaptive design' or if it has to be inferred and to identify whether these methods are applied prospectively or concurrently.Methods: Three databases; Embase, Ovid and PubMed were chosen to conduct the literature search. The inclusion criteria for the review were phase II, phase III and phase II/III randomised controlled trials within the field of Oncology that published trial results in 2015. A variety of search terms related to adaptive designs were used.Results: A total of 734 results were identified, after screening 54 were eligible. Adaptive designs were more commonly applied in phase III confirmatory trials. The majority of the papers performed an interim analysis, which included some sort of stopping criteria. Additionally only two papers explicitly stated the term 'adaptive design' and therefore for most of the papers, it had to be inferred that adaptive methods was applied. Sixty-five applications of adaptive design methods were applied, from which the most common method was an adaptation using group sequential methods.Conclusions: This review indicated that the reporting of adaptive design methodology within clinical trials needs improving. The proposed extension to the current CONSORT 2010 guidelines could help capture adaptive design methods. Furthermore provide an essential aid to those involved with clinical trials. [ABSTRACT FROM AUTHOR]

Background: This study involved a scoping review to explore factors influencing dental hygienist demand and supply in high-income countries. Methods: A six-stage scoping review was conducted with separate search strategies tailored to four databases (MEDLINE, CINAHL, Google Scholar, and Google) plus a targeted scan of dental hygienist organization websites. This yielded 2,117 unique citations, leading to 148 articles included in the review. Results: Nearly half of the articles (47%) focused on the United States, with 11% on Canada. Most articles (91%) were in English, alongside 13 in Korean and one in French. Journal articles comprised 62% of the publications, followed by reports/working papers (11%) and websites (11%). Other types included conference abstracts, policy briefs, and presentation slides. Content-wise, 47% were original research, with analysis articles (14%), commentaries (11%), and reviews (8%) also present. The articles were coded into three main categories: workforce characteristics/projections, factor-specific analyses, and workforce opportunities. The articles on workforce characteristics covered demographic, geographic, and employment aspects of dental hygienists, along with projections for supply and demand using simulation modelling and geospatial analyses. Factor-specific articles investigated the (1) working environment, (2) policy/regulatory/training environment, (3) job/career satisfaction and related human resource issues, and (4) scope of practice. The third key category of articles highlighted opportunities for expanding the workforce through alternative models in different sectors/settings (e.g., public health, primary care, long-term care, hospitals, mobile outreach, and non-clinical roles including research, education and leadership) and for a range of vulnerable or underserved populations (e.g., geriatric and pediatric populations, persons with disabilities, those living in rural/remote areas, Indigenous peoples, and incarcerated people). Conclusions: This review provides a comprehensive documentation of the current state of the dental hygienist workforce, compiling factors affecting demand and supply, and highlighting opportunities for the dental hygienist workforce in Canada and other high-income countries. The findings offer a foundation for future research, highlighting the need for more focused and rigorous reviews and underscoring the necessity of high-quality studies to verify the effectiveness of various interventions and policies. This is crucial to address dental hygienist workforce challenges and ensure the sustainability and effectiveness of oral health care delivery. [ABSTRACT FROM AUTHOR]

While the health of and healthcare use by migrants has received significant scholarly and policy attention in Australia, current debates highlight that a critical examination of the theoretical underpinnings of these inquiries and responses is needed. We conducted a systematic review and critical interpretive synthesis (CIS) to critically examine how the policy and scholarly literature conceptualises migrants' interactions with and experiences of the Australian health system. Guided by PRISMA, we searched for literature without imposing any limits. We also searched key State and Federal Government websites for relevant policy documents. Our initially broad inclusion criteria became refined as the CIS progressed. We prioritised the likely relevance and theoretical contribution of the papers to our inquiry over methodological quality. The CIS of 104 papers revealed that the Australian scholarly literature and policy documents consistently homogenise and reduce migrants according to an assumed, (1) cultural identity, (2) linguistic affiliation, and/or (3) broad geographic origin. Based on these three critiques and drawing on the theoretical literature, we propose a synthesising argument on how the Australian literature could better conceptualise migrants' experiences of the Australian health system. We contend that both research and policy should explicitly recognise and engage with the multifaceted and shifting ways that migrants define themselves, generally, and during their encounters with destination country health systems. Engagement with this notion is necessary for also understanding how aspects of migrants' identities are dynamically co-constructed during their interactions with the health system. These understandings have implications for improving the design and implementation of policies and programs directed at improving the responsiveness of Australia's health system to the needs and expectations of migrant communities specifically, and destination countries broadly. [ABSTRACT FROM AUTHOR]

Background: Oral health is a critical issue for public health and poor oral health is associated with significant chronic health conditions and lower quality of life. There has been little focus on providing oral health care to people who receive care in their own homes, despite the high risk of poor oral health in older people. Nurses practicing in the community are well placed to deliver this care, but little is known about how to build this capability through education or training interventions. Methods: A scoping review methodology was employed to find and review studies of oral health interventions involving populations of people receiving care in their own home or those nurses who deliver this care. The research question asked what previous research tells us about oral health interventions delivered by nurses in the community. Data was extracted for four areas: setting and type of intervention, patient outcomes, changes to nursing practice and implementation and process evaluations of interventions. Results: Two thousand eighty papers were found from the searches, and only nine were ultimately deemed eligible for inclusion in the review. Included studies spanned community nursing for older people (n = 3) and health visiting or community nursing for children and infants (n = 6). Patient outcomes were generally positive, but this is based on a low level of evidence. Changes to practice including increased oral health care administered by nurses were found, but this required professional support to be sustainable. Conclusions: This review has found that there is a clear gap in the research around interventions designed to be used by community nurses to improve oral health care for people receiving care in their own homes. The results also suggest that any future intervention must make use of a participatory, co-design approach and consider the complex setting of nursing practice in the community and the barriers to delivering this care, such as time pressure and lack of prior experience. [ABSTRACT FROM AUTHOR]

Background: Having a sufficient and well-functioning health workforce is crucial for reducing the burden of disease and premature death. Health workforce development, focusing on availability, recruitment, retention, and education, is inseparable from acceptability, motivation, burnout, role and responsibility, and performance. Each aspect of workforce development may face several challenges, requiring specific strategies. However, there was little evidence on barriers and strategies towards comprehensive health workforce development. Therefore, this review explored barriers and strategies for health workforce development at the primary health care level around the world. Methods: A scoping review of reviews was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews. The article search was performed in Google Scholar, PubMed, Web of Science, and EMBASE. We used EndNote x9 for managing the collected articles, screening processes, and citation purpose. The scoping review included any kind of review articles on the application of health workforce development concepts, such as availability, recruitment, retention, role and responsibility, education and training, motivation, and burnout, with primary health care and published in English anywhere in the world. Based on the concepts above, barriers and strategies for health workforce development were identified. The findings were synthesized qualitatively based on the building blocks of the health system framework. The analysis involved specific activities such as familiarization, construction of the thematic framework, indexing, charting, and interpretation. The results were presented in texts, tables, and figures. Results: The search strategies yielded 7,276 papers were found. Of which, 69 were included in the scoping review. The most frequently cited barriers were financial challenges and issues related to health care delivery, such as workloads. Barriers affecting healthcare providers directly, including lack of training and ineffective teamwork, were also prominent. Other health system and governance barriers include lack of support, unclear responsibility, and inequity. Another notable barrier was the shortage of health care technology, which pertains to both health care supplies and information technology. The most common cited effective strategies were ongoing support and supervision, engaging with communities, establishing appropriate primary care settings, financial incentives, fostering teamwork, and promoting autonomous health care practice. Conclusions: Effective leadership/governance, a robust health financing system, integration of health information and technology, such as mobile health and ensuring a consistent supply of adequate resources are also vital components of primary health care workforce development. The findings highlight the importance of continuous professional development, which includes training new cadres, implementing effective recruitment and retention mechanisms, optimising the skill mix, and promoting workplace wellness. These elements are essential in fostering a well-trained and resilient primary health care workforce. [ABSTRACT FROM AUTHOR]

Background: This paper explores the extent of community-level stock-out of essential medicines among community health workers (CHWs) in low- and middle-income countries (LMICs) and identifies the reasons for and consequences of essential medicine stock-outs.Methods: A systematic review was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Five electronic databases were searched with a prespecified strategy and the grey literature examined, January 2006-March 2021. Papers containing information on (1) the percentage of CHWs stocked out or (2) reasons for stock-outs along the supply chain and consequences of stock-out were included and appraised for risk of bias. Outcomes were quantitative data on the extent of stock-out, summarized using descriptive statistics, and qualitative data regarding reasons for and consequences of stock-outs, analyzed using thematic content analysis and narrative synthesis.Results: Two reviewers screened 1083 records; 78 evaluations were included. Over the last 15 years, CHWs experienced stock-outs of essential medicines nearly one third of the time and at a significantly (p < 0.01) higher rate than the health centers to which they are affiliated (28.93% [CI 95%: 28.79-29.07] vs 9.17% [CI 95%: 8.64-9.70], respectively). A comparison of the period 2006-2015 and 2016-2021 showed a significant (p < 0.01) increase in CHW stock-out level from 26.36% [CI 95%: 26.22-26.50] to 48.65% [CI 95%: 48.02-49.28] while that of health centers increased from 7.79% [95% CI 7.16-8.42] to 14.28% [95% CI 11.22-17.34]. Distribution barriers were the most cited reasons for stock-outs. Ultimately, patients were the most affected: stock-outs resulted in out-of-pocket expenses to buy unavailable medicines, poor adherence to medicine regimes, dissatisfaction, and low service utilization.Conclusions: Community-level stock-out of essential medicines constitutes a serious threat to achieving universal health coverage and equitable improvement of health outcomes. This paper suggests stock-outs are getting worse, and that there are particular barriers at the last mile. There is an urgent need to address the health and non-health system constraints that prevent the essential medicines procured for LMICs by international and national stakeholders from reaching the people who need them the most. [ABSTRACT FROM AUTHOR]

Background: The Russia-Ukraine war has undeniably impacted global science and healthcare in Ukraine. Many Ukrainian researchers have had their projects disrupted by this war, either due to loss of life, displacement, or destruction of resources. Despite these challenges, these researchers have sought to make their voices heard. This scoping review highlights the trend of healthcare-related publications on the current Russia-Ukraine war and characterizes the contribution of Ukrainian authors to these publications. Method: A comprehensive literature search was performed using two databases (Scopus and Pubmed) for publications related to the ongoing Russia-Ukraine war. We included articles only related to healthcare. We then extracted and analyzed bibliometric data. Result: One hundred and eighty-three articles were identified, including 12 (6.6%) original articles, 26 (14.2%) cross-sectional studies, 19 (10.4%) letters to the editor, 10 (5.5%) commentaries, 5 (2.7%) perspectives, 35 (19.1%) editorials, 2 (1.1%) randomized controlled trials, 11(6.0%) correspondences, 13 (7.1%) opinions, 8 (4.4%) reviews and 42 (23.0%) are identified as others. 180 (98.4%) studies were in English, and 3 (1.7%) were in German. 54 (29.5%) papers on the war had at least one author affiliated with a Ukrainian institution, and 29 (15.9%) studies had authors with Ukrainian affiliation as first authors. Conclusion: our study shows that there has been a significant number of publications on the Russia-Ukraine war and only a small portion of first authors, co-authors, and last authors of these publications are affiliated to an institution in Ukraine. Therefore, despite the relatively high number of publications, most publications do not arise from the perspective of Ukrainian authors. [ABSTRACT FROM AUTHOR]

While transnational social ties and exchanges are a core concern within migration studies, health researchers have often overlooked their importance. Continuous and circular exchanges of information within transnational networks, also defined as social remittances, facilitate the diffusion of innovations, potentially driving contemporary social and cultural change. Influences on health, wellbeing, and care-seeking are important, but under-researched, dimensions for consideration. We undertook a systematic narrative evidence synthesis to describe the current state of knowledge in this area and to identify gaps and future directions for health researchers to take. Between April 2017 and May 2019, an iterative series of searches in Medline, Embase, PsycINFO and PubMed, plus backward and forward citation searches identified 1173 potential papers. Screening resulted in 36 included papers, eighteen focused on migrant populations and eighteen on those who remain behind. The top three health topics were health-seeking strategies, sexual and reproductive health issues, and healthcare support. And, while not always explicitly identified, mental health and wellbeing was a further prominent, cross-cutting theme. Articles on migrant populations were all conducted in the global North and 13 out of 18 used qualitative methods. Five main themes were identified: therapeutic effect of the continuing social relationships, disrupted social relationships, hybridisation of healthcare, facilitation of connections to healthcare providers, and factors encouraging or undermining transnational social exchanges. Papers concerned with those who remain behind were mainly focused on the global South and used a mix of qualitative and quantitative approaches. Four main themes were identified: transnational transfer of health-related advice, norms, and support; associations between migrant linkages and health behaviours/outcomes; transnational collective transfer of health knowledge; and power and resistance in exchanges. Findings suggest that transnational social exchanges can both support and undermine the health of migrants and those who remain behind. This review confirms that the volume and quality of research in this area must be increased so that health policy and practice can be informed by a better understanding of these important influences on the health of both migrants and those who remain behind. [ABSTRACT FROM AUTHOR]

Background: Until now, scholarship on innovation processes in healthcare systems lack an in-depth appreciation of tensions. Tensions often revolve around barriers and result from individual assessments and prioritizations that guide actions to eventually overcome these barriers. In order to develop a more differentiated understanding of tensions' role in healthcare innovation processes, this paper aims to shed light on the multifaceted ways in which tensions emerge, are being dealt with, and how they hinder or, at times, facilitate innovation processes.Methods: A systematic review of published and grey literature was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline. The review involved searching three databases for original research articles and manually searching citations. Twenty-nine original full texts were identified, evaluated, and coded. These include papers on innovation in healthcare systems that investigated innovation-related organizational tensions. The findings were synthesized into different types of tensions in healthcare system innovation and the descriptions of the conflicting elements. We also analyzed the investigated innovations by type, process stages, and across different countries and healthcare systems.Results: A total of forty-two tensions were identified and grouped into nine categories. Organizing tensions were predominant, followed by learning/belonging, performing, and performing/organizing tensions. Tensions most frequently occurred in the implementation phase and in the form of a dilemma. Included studies were conducted mainly in government-funded healthcare systems.Conclusion: Our data suggest that innovation processes in healthcare systems are impaired by conflicts between contradictory elements, working cultures, and convictions and the organizational and regulatory context. Since the majority of the tensions we collected in our study can be addressed, future policy-making and research should take advantage of this fact and develop strategies that significantly influence the successful management of tensions and thus improve the implementation of innovations. [ABSTRACT FROM AUTHOR]

Background: Interventions aiming to coordinate services for the community-based dementia population vary in components, organisation and implementation. In this review we aimed to investigate the views of stakeholders on the key components of community-based interventions coordinating care in dementia.Methods: We searched four databases from inception to June 2015; Medline, The Cochrane Library, EMBASE and PsycINFO, this was aided by a search of four grey literature databases, and backward and forward citation tracking of included papers. Title and abstract screening was followed by a full text screen by two independent reviewers, and quality was assessed using the CASP appraisal tool. We then conducted thematic synthesis on extracted data.Results: A total of seven papers from five independent studies were included in the review, and encompassed the views of over 100 participants from three countries. Through thematic synthesis we identified 32 initial codes that were grouped into 5 second-order themes: (1) case manager had four associated codes and described preferences for the case manager personal and professional attributes, including a sound knowledge in dementia and availability of local services; (2) communication had five associated codes and emphasized the importance stakeholders placed on multichannel communication with service users, as well as between multidisciplinary teams and across organisations; (3) intervention had 11 associated codes which focused primarily on the practicalities of implementation such as the contact type and frequency between case managers and service users, and the importance of case manager training and service evaluation; (4) resources had five associated codes which outlined stakeholder views on the required resources for coordinating interventions and potential overlap with existing resources, as well as arising issues when available resources do not meet those required for successful implementation; and (5) support had seven associated codes that reflect the importance that was placed on the support network around the case manager and the investment of professionals involved directly in care as well as the wider professional network.Conclusion: The synthesis of relevant qualitative studies has shown how various stakeholder groups considered dementia care coordination interventions to be acceptable, useful and appropriate for dementia care, and have clear preferences for components, implementation methods and settings of these interventions. By incorporating stakeholders' perspectives and preferences when planning and developing coordinating interventions we may increase the likelihood of successful implementation and patient benefits. [ABSTRACT FROM AUTHOR]

Background: Cardiovascular disease (CVD) is the first cause of death globally, with huge costs worldwide. Most cases of CVD could be prevented by addressing behavioural risk factors. Among these factors, there is physical and amateur sports activity (PASA), which has a linear negative correlation with the risk of CVD. Nevertheless, attempts to encourage PASA, as exercise prescription programmes, achieved little impact at the community-wide level. A new frontier to promote PASA is represented by mobile health tools, such as exergaming, mobile device apps, health wearables, GPS/GIS and virtual reality. Nevertheless, there has not yet been any evident turnabout in patient active involvement towards CVD prevention, and inactivity rates are even increasing. This study aims at framing the state of the art of the literature about the use of m-health in supporting PASA, as a user-centric innovation strategy, to promote co-production health policies aiming at CVD prevention.Methods: A mixed-method systematic literature review was conducted in the fields of health and healthcare management to highlight the intersections between PASA promotion and m-health tools in fostering co-produced services focused on CVD prevention. The literature has been extracted by the PRISMA logic application. The resulting sample has been first statistically described by a bibliometric approach and then further investigated with a conceptual analysis of the most relevant contributions, which have been qualitatively analysed.Results: We identified 2,295 studies, on which we ran the bibliometric analysis. After narrowing the research around the co-production field, we found 10 papers relevant for the concept analysis of contents. The interest about the theme has increased in the last two decades, with a high prevalence of contributions from higher income countries and those with higher CVD incidence. The field of research is highly multi-disciplinary; most of documents belong to the medical field, with only a few interconnections with the technology and health policy spheres. Although the involvement of patients is recognized as fundamental for CVD prevention through PASA, co-design schemes are still lacking at the public management level.Conclusions: While the link between the subjects of motor activity, medicine and technology is clear, the involvement of citizens in the service delivery process is still underinvestigated, especially the issue concerning how "value co-creation" could effectively be applied by public agencies. In synthesis, the analysis of the role of co-production as a system coordination method, which is so important in designing and implementing preventive care, is still lacking. [ABSTRACT FROM AUTHOR]

Introduction: Ensuring healthcare systems provide equitable, high quality care is critical to their users' overall health and wellbeing. Typically, systems use various performance frameworks and related indicators to monitor and improve healthcare. Although these frameworks usually include equity, the extent that equity is reflected in these measurements remains unclear. In order to create a system that meets patients' needs, addressing this uncertainty is important. This paper presents findings from a scoping review that sought to answer the question 'How is equity conceptualized in healthcare systems when assessing healthcare system performance?'. Methods: Levac's scoping review approach was used to locate relevant articles and create a protocol. Included, peer-reviewed articles were published between 2015 to 2020, written in English and did not discuss oral health and clinician training. These healthcare areas were excluded as they represent large, specialized bodies of literature beyond the scope of this review. Online databases (e.g., MEDLINE, CINAHL Plus) were used to locate articles. Results: Eight thousand six hundred fifty-five potentially relevant articles were identified. Fifty-four were selected for full review. The review yielded 16 relevant articles. Six articles emanated from North America, six from Europe and one each from Africa, Australia, China and India respectively. Most articles used quantitative methods and examined various aspects of healthcare. Studies centered on: indicators; equity policies; evaluating the equitability of healthcare systems; creating and/or testing equity tools; and using patients' sociodemographic characteristics to examine healthcare system performance. Conclusion: Although equity is framed as an important component of most healthcare systems' performance frameworks, the scarcity of relevant articles indicate otherwise. This scarcity may point to challenges systems face when moving from conceptualizing to measuring equity. Additionally, it may indicate the limited attention systems place on effectively incorporating equity into performance frameworks. The disjointed and varied approaches to conceptualizing equity noted in relevant articles make it difficult to conduct comparative analyses of these frameworks. Further, these frameworks' strong focus on users' social determinants of health does not offer a robust view of performance. More work is needed to shift these narrow views of equity towards frameworks that analyze healthcare systems and not their users. [ABSTRACT FROM AUTHOR]

Background: Direct out-of-pocket payments (OOP) are among the most important financing mechanisms in many health systems, especially in developing countries, adversely affecting equality and leading vulnerable groups to poverty. Therefore, this scoping review study was conducted to identify the strategies involving OOP reduction in health systems. Methods: Articles published in English on strategies related to out-of-pocket payments were Searched and retrieved in the Web of Science, Scopus, PubMed, and Embase databases between January 2000 and November 2020, following PRISMA guidelines. As a result, 3710 papers were retrieved initially, and 40 were selected for full-text assessment. Results: Out of 40 papers included, 22 (55%) and 18 (45%) of the study were conducted in developing and developed countries, respectively. The strategies were divided into four categories based on health system functions: health system stewardship, creating resources, health financing mechanisms, and delivering health services.As well, developing and developed countries applied different types of strategies to reduce OOP. Conclusion: The present review identified some strategies that affect the OOP payments According to the health system functions framework. Considering the importance of stewardship, creating resources, the health financing mechanisms, and delivering health services in reducing OOP, this study could help policymakers make better decisions for reducing OOP expenditures. [ABSTRACT FROM AUTHOR]

Background: Evidence from the context of local health ecosystems is highly relevant for research and policymaking to understand geographical variations in outcomes of health care delivery. In mental health systems, the analysis of context presents particular challenges related to their complexity and to methodological difficulties. Method guidelines and standard recommendations for conducting context analysis of local mental health care are urgently needed. This scoping study reviews current methods of context analysis in mental health systems to establish the parameters of research activity examining availability and capacity of care at the local level, and to identify any gaps in the literature.Methods: A scoping review based on a systematic search of key databases was conducted for the period 2005-2016. A systems dynamics/complexity approach was adopted, using a modified version of Tansella and Thornicroft's matrix model of mental health care as the conceptual framework for our analysis.Results: The lack of a specific terminology in the area meant that from 10,911 titles identified at the initial search, only 46 papers met inclusion criteria. Of these, 21 had serious methodological limitations. Fifteen papers did not use any kind of formal framework, and five of those did not describe their method. Units of analysis varied widely and across different levels of the system. Six instruments to describe service availability and capacity were identified, of which three had been psychometrically validated. A limitation was the exclusion of grey literature from the review. However, the imprecise nature of the terminology, and high number of initial results, makes the inclusion of grey literature not feasible.Conclusion: We identified that, in spite of its relevance, context studies in mental health services is a very limited research area. Few validated instruments are available. Methodological limitations in many papers mean that the particular challenges of mental health systems research such as system complexity, data availability and terminological variability are generally poorly addressed, presenting a barrier to valid system comparison. The modified Thornicroft and Tansella matrix and related ecological production of care model provide the main model for research within the area of health care ecosystems. [ABSTRACT FROM AUTHOR]

Background: Non-beneficial treatment is closely tied to inappropriate treatment at the end-of-life. Understanding the interplay between how and why these situations arise in acute care settings according to the various stakeholders is pivotal to informing decision-making and best practice at end-of-life. Aim: To define and understand determinants of non-beneficial and inappropriate treatments for patients with a non-cancer diagnosis, in acute care settings at the end-of-life. Design: Systematic review of peer-reviewed studies focusing on the above and conducted in upper-middle- and high-income countries. A narrative synthesis was undertaken, guided by Realist principles. Data sources: Cochrane; PubMed; Scopus; Embase; CINAHL; and Web of Science. Results: Sixty-six studies (32 qualitative, 28 quantitative, and 6 mixed-methods) were included after screening 4,754 papers. Non-beneficial treatment was largely defined as when the burden of treatment outweighs any benefit to the patient. Inappropriate treatment at the end-of-life was similar to this, but additionally accounted for patient and family preferences. Contexts in which outcomes related to non-beneficial treatment and/or inappropriate treatment occurred were described as veiled by uncertainty, driven by organizational culture, and limited by profiles and characteristics of involved stakeholders. Mechanisms relating to 'Motivation to Address Conflict & Seek Agreement' helped to lessen uncertainty around decision-making. Establishing agreement was reliant on 'Valuing Clear Communication and Sharing of Information'. Reaching consensus was dependent on 'Choices around Timing & Documenting of end-of-life Decisions'. Conclusion: A framework mapping determinants of non-beneficial and inappropriate end-of-life treatment is developed and proposed to be potentially transferable to diverse contexts. Future studies should test and update the framework as an implementation tool. Trial registration: PROSPERO Protocol CRD42021214137. [ABSTRACT FROM AUTHOR]

Background: Recommendations in clinical practice guidelines for non-specific low back pain (NSLBP) are not necessarily translated into practice. Multiple studies have investigated different interventions to implement best evidence into clinical practice yet no synthesis of these studies has been carried out to date. The aim of this study was to systematically review available studies to determine whether implementation interventions in this field have been effective and to identify which strategies have been most successful in changing healthcare practitioner behaviours and improving patient outcomes.Methods: A systematic review was undertaken, searching electronic databases until end of December 2012 plus hand searching, writing to key authors and using prior knowledge of the field to identify papers. Included studies evaluated an implementation intervention to improve the management of NSLBP in clinical practice, measured key outcomes regarding change in practitioner behaviour and/or patient outcomes and subjected their data to statistical analysis. The Cochrane Effective Practice and Organisation of Care (EPOC) recommendations about systematic review conduct were followed. Study inclusion, data extraction and study risk of bias assessments were conducted independently by two review authors.Results: Of 7654 potentially eligible citations, 17 papers reporting on 14 studies were included. Risk of bias of included studies was highly variable with 7 of 17 papers rated at high risk. Single intervention or one-off implementation efforts were consistently ineffective in changing clinical practice. Increasing the frequency and duration of implementation interventions led to greater success with those continuously ongoing over time the most successful in improving clinical practice in line with best evidence recommendations.Conclusions: Single intervention or one-off implementation interventions may seem attractive but are largely unsuccessful in effecting meaningful change in clinical practice for NSLBP. Increasing frequency and duration of implementation interventions seems to lead to greater success and the most successful implementation interventions used consistently sustained strategies. [ABSTRACT FROM AUTHOR]

Background: Institutional Health Partnerships are long-term, institution to institution partnerships between high income and low and middle income countries which seek to build capacity and strengthen health institutions in order to improve health service delivery and outcomes. Funding for Institutional Health Partnerships has increased in recent years. This paper outlines a rapid evidence review on the effectiveness of this modality.Methods: A rapid evidence review of published and grey literature was conducted. Content relating to the effectiveness of working in partnership and methods and frameworks used were extracted and analysed. The results of this analysis were used to structure a discussion regarding the next steps to strengthen the evidence base for the effectiveness of institutional health partnerships.Results: The evidence review, including citation mapping, returned 27 published papers and 17 grey literature documents that met all of the inclusion criteria. Most of the literature did not meet the high standards of formal academic rigour and there was no original research amongst this literature that specifically addressed the effectiveness of institutional health partnerships. This was not surprising given institutional health partnerships do not lend themselves easily to case control studies and randomised control trials due to their high level of diversity and operation in complex social systems. There was, however, a body of practice based knowledge and experience.Conclusions: Evidence for the effectiveness of Institutional Health Partnerships is thin both in terms of quantity and academic rigour. There is a need to better define and differentiate Institutional Health Partnerships in order to measure and compare effectiveness across such a diverse group. Effectiveness needs to be measured at the level of individual partnerships, the bodies that facilitate partnership programmes and the level of health service delivery. There is a need to develop indicators and frameworks that specifically address the benefits and values of partnership working and how these relate to effectiveness. These indicators need to be content neutral of specific interventions which are already measured through routine project monitoring and evaluation. This will allow the development of methodological pathways to assess the effectiveness of institutional health partnerships. Until more primary research is conducted or published there is little benefit in further systematic reviews. [ABSTRACT FROM AUTHOR]

Background: While there is an extensive literature on Health System (HS) strengthening and on the performance of specific HSs, there are few exhaustive syntheses of the challenges HSs are facing worldwide. This paper reports the findings of a scoping review aiming to classify the challenges of HSs investigated in the scientific literature. Specifically, it determines the kind of research conducted on HS challenges, where it was performed, in which health sectors and on which populations. It also identifies the types of challenge described the most and how they varied across countries.Methods: We searched 8 databases to identify scientific papers published in English, French and Italian between January 2000 and April 2016 that addressed HS needs and challenges. The challenges reported in the articles were classified using van Olmen et al.'s dynamic HS framework. Countries were classified using the Human Development Index (HDI). Our analyses relied on descriptive statistics and qualitative content analysis.Results: 292 articles were included in our scoping review. 33.6% of these articles were empirical studies and 60.1% were specific to countries falling within the very high HDI category, in particular the United States. The most frequently researched sectors were mental health (41%), infectious diseases (12%) and primary care (11%). The most frequently studied target populations included elderly people (23%), people living in remote or poor areas (21%), visible or ethnic minorities (15%), and children and adolescents (15%). The most frequently reported challenges related to human resources (22%), leadership and governance (21%) and health service delivery (24%). While health service delivery challenges were more often examined in countries within the very high HDI category, human resources challenges attracted more attention within the low HDI category.Conclusions: This scoping review provides a quantitative description of the available evidence on HS challenges and a qualitative exploration of the dynamic relationships that HS components entertain. While health services research is increasingly concerned about the way HSs can adopt innovations, little is known about the system-level challenges that innovations should address in the first place. Within this perspective, four key lessons are drawn as well as three knowledge gaps. [ABSTRACT FROM AUTHOR]

Background: To improve consistency and streamline development and publication of clinical guidelines (GL), there is a need for appropriate software support. We have found few specific tools for the actual authoring and maintaining of GLs, and correspondingly few analyses or reviews of GL development tool functionality. In order to assist GL developers in selecting and evaluating tools, this study tries to address the perceived gap by pursuing four goals: 1) identifying available tools, 2) reviewing a representative group of tools and their supported functionalities, 3) uncovering themes of features that the studied tools support, and 4) compare the selected tools with respect to the themes.Methods: We conducted a literature search using PubMed and Google Scholar in order to find GL development tools (GDT). We also explored tools and Content Management Systems (CMS) used in representative organisations and international communities that develop and maintain GLs. By reading a selected representative group of five GL tool manuals, exploring tools hands-on, we uncovered 8 themes of features. All found tools were compared according to these themes in order to identify the level of functionality they offer to support the GL development and publishing process. In order to limit the scope, tools for designing computer-interpretable/executable GL are excluded.Results: After finding 1552 published papers, contacting 7 organizations and international communities, we identified a total of 19 unique tools, of which 5 tools were selected as representative in this paper. We uncovered a total of 8 themes of features according to the identified functionalities that each tool provides. Four features were common among tools: Collaborative authoring process support, user access control, GL repository management, electronic publishing. We found that the GRADE methodology was supported by three of the reviewed tools, while only two tools support annotating GL with MeSH terms. We also identified that monitoring progress, reference management, Managing versions (version control), and Change control (tracking) were often the missing features.Conclusion: The results can promote sector discussion and eventual agreement on important tool functionality. It may aid tool and GL developers towards more efficient, and effective, GL authoring. [ABSTRACT FROM AUTHOR]

Patient travel across borders to access healthcare is becoming increasingly common and widespread. Patients moving from high income to middle income countries for healthcare is well documented, with patients seeking treatments that are cheaper or more readily available than at home. Less well understood is when patients move from one low income country to another or from a low income country to a higher income country. In this paper, a realist review was undertaken to explore why, in what contexts and how patients from lower income countries travel to countries with the same, or more advanced, economies for planned healthcare. Based on an initial scoping of the literature and discussions with key informants, we generated an initial theory and set of propositions about why, how, who and in what contexts people cross international borders for planned healthcare. We then systematically located and synthesized (1) peer-reviewed studies from the Scopus, Embase, Web of Science and Econlit databases; (2) non-indexed reports using key informants and Google; and (3) papers from the reference lists of included documents, to glean supportive or contradictory evidence for our initial propositions. As we reviewed the literature and extracted our data, we drew on the work of Pierre Bourdieu to understand the interplay between material and non-material capital and cognitive processes in decisions to cross borders for healthcare. Patient travel was largely undertaken due to a lack of services in the home country and/or unacceptability of local services, with decisions on when, and where, to travel, usually made within the patient's social networks. They were able to travel via use of multiple resources, including social networks, economic and cultural capital, and habitus. Those patients with greater volumes of the aforementioned factors had greater healthcare options; however, even those with limited resources engaged in patient travel. Patient movement challenges traditional ways of thinking about public health and the notion of health systems contained within the nation state. Further research is needed to better understand the effects of patient travel, and how to harness the benefits of patient travel without exacerbating existing health inequalities. [ABSTRACT FROM AUTHOR]

Background: Globally, the rate of emergency hospital admissions is increasing. However, little evidence exists to inform the development of interventions to reduce unplanned Emergency Department (ED) attendances and hospital admissions. The objective of this evidence synthesis was to review the evidence for interventions, conducted during the patient's journey through the ED or acute care setting, to manage people with an exacerbation of a medical condition to reduce unplanned emergency hospital attendance and admissions.Methods: A rapid evidence synthesis, using a systematic literature search, was undertaken in the electronic data bases of MEDLINE, EMBASE, CINAHL, the Cochrane Library and Web of Science, for the years 2000-2014. Evidence included in this review was restricted to Randomised Controlled Trials (RCTs) and observational studies (with a control arm) reported in peer-reviewed journals. Studies evaluating interventions for patients with an acute exacerbation of a medical condition in the ED or acute care setting which reported at least one outcome related to ED attendance or unplanned admission were included.Results: Thirty papers met our inclusion criteria: 19 intervention studies (14 RCTs) and 11 controlled observational studies. Sixteen studies were set in the ED and 14 were conducted in an acute setting. Two studies (one RCT), set in the ED were effective in reducing ED attendance and hospital admission. Both of these interventions were initiated in the ED and included a post-discharge community component. Paradoxically 3 ED initiated interventions showed an increase in ED re-attendance. Six studies (1 RCT) set in acute care settings were effective in reducing: hospital admission, ED re-attendance or re-admission (two in an observation ward, one in an ED assessment unit and three in which the intervention was conducted within 72 h of admission).Conclusions: There is no clear evidence that specific interventions along the patient journey from ED arrival to 72 h after admission benefit ED re-attendance or readmission. Interventions targeted at high-risk patients, particularly the elderly, may reduce ED utilization and warrant future research. Some interventions showing effectiveness in reducing unplanned ED attendances and admissions are delivered by appropriately trained personnel in an environment that allows sufficient time to assess and manage patients. [ABSTRACT FROM AUTHOR]

Introduction: Healthcare organisations serve clients from diverse Indigenous and other ethnic and racial groups on a daily basis, and require appropriate client-centred systems and services for provision of optimal healthcare. Despite advocacy for systems-level approaches to cultural competence, the primary focus in the literature remains on competency strategies aimed at health promotion initiatives, workforce development and student education. This paper aims to bridge the gap in available evidence about systems approaches to cultural competence by systematically mapping key concepts, types of evidence, and gaps in research. Methods: A literature search was completed as part of a larger systematic search of evaluations and measures of cultural competence interventions in health care in Canada, the United States, Australia and New Zealand. Seventeen peer-reviewed databases, 13 websites and clearinghouses, and 11 literature reviews were searched from 2002 to 2015. Overall, 109 studies were found, with 15 evaluating systems-level interventions or describing measurements. Thematic analysis was used to identify key implementation principles, intervention strategies and outcomes reported. Results: Twelve intervention and three measurement studies met our inclusion criteria. Key principles for implementing systems approaches were: user engagement, organisational readiness, and delivery across multiple sites. Two key types of intervention strategies to embed cultural competence within health systems were: audit and quality improvement approaches and service-level policies or strategies. Outcomes were found for organisational systems, the client/practitioner encounter, health, and at national policy level. Discussion and implications: We could not determine the overall effectiveness of systems-level interventions to reform health systems because interventions were context-specific, there were too few comparative studies and studies did not use the same outcome measures. However, examined together, the intervention and measurement principles, strategies and outcomes provide a preliminary framework for implementation and evaluation of systems-level interventions to improve cultural competence. Identified gaps in the literature included a need for cost and effectiveness studies of systems approaches and explication of the effects of cultural competence on client experience. Further research is needed to explore the extent to which cultural competence improves health outcomes and reduces ethnic and racially-based healthcare disparities. [ABSTRACT FROM AUTHOR]

Background: Community health workers (CHWs) are uniquely placed to link communities with the health system, playing a role in improving the reach of health systems and bringing health services closer to hard-to-reach and marginalised groups. A systematic review was conducted to determine the extent of equity of CHW programmes and to identify intervention design factors which influence equity of health outcomes.Methods: In accordance with our published protocol, we systematically searched eight databases from 2004 to 2014 for quantitative and qualitative studies which assessed access, utilisation, quality or community empowerment following introduction of a CHW programme according to equity stratifiers (place of residence, gender, socio-economic position and disability). Thirty four papers met inclusion criteria. A thematic framework was applied and data extracted and managed, prior to charting and thematic analysis.Results: To our knowledge this is the first systematic review that describes the extent of equity within CHW programmes and identifies CHW intervention design features which influence equity. CHW programmes were found to promote equity of access and utilisation for community health by reducing inequities relating to place of residence, gender, education and socio-economic position. CHWs can also contribute towards more equitable uptake of referrals at health facility level. There was no clear evidence for equitable quality of services provided by CHWs and limited information regarding the role of the CHW in generating community empowerment to respond to social determinants of health. Factors promoting greater equity of CHW services include recruitment of most poor community members as CHWs, close proximity of services to households, pre-existing social relationship with CHW, provision of home-based services, free service delivery, targeting of poor households, strengthened referral to facility, sensitisation and mobilisation of community. However, if CHW programmes are not well planned some of the barriers faced by clients at health facility level can replicate at community level.Conclusions: CHWs promote equitable access to health promotion, disease prevention and use of curative services at household level. However, care must be taken by policymakers and implementers to take into account factors which can influence the equity of services during planning and implementation of CHW programmes. [ABSTRACT FROM AUTHOR]

Background: Involving collaborators and partners in research may increase relevance and uptake, while reducing health and social inequities. Collaborators and partners include people and groups interested in health research: health care providers, patients and caregivers, payers of health research, payers of health services, publishers, policymakers, researchers, product makers, program managers, and the public. Evidence syntheses inform decisions about health care services, treatments, and practice, which ultimately affect health outcomes. Our objectives are to: A. Identify, map, and synthesize qualitative and quantitative findings related to engagement in evidence syntheses B. Explore how engagement in evidence synthesis promotes health equity C. Develop equity-oriented guidance on methods for conducting, evaluating, and reporting engagement in evidence syntheses Methods: Our diverse, international team will develop guidance for engagement with collaborators and partners throughout multiple sequential steps using an integrated knowledge translation approach: 1. Reviews. We will co-produce 1 scoping review, 3 systematic reviews and 1 evidence map focusing on (a) methods, (b) barriers and facilitators, (c) conflict of interest considerations, (d) impacts, and (e) equity considerations of engagement in evidence synthesis. 2. Methods study, interviews, and survey. We will contextualise the findings of step 1 by assessing a sample of evidence syntheses reporting on engagement with collaborators and partners and through conducting interviews with collaborators and partners who have been involved in producing evidence syntheses. We will use these findings to develop draft guidance checklists and will assess agreement with each item through an international survey. 3. Consensus. The guidance checklists will be co-produced and finalised at a consensus meeting with collaborators and partners. 4. Dissemination. We will develop a dissemination plan with our collaborators and partners and work collaboratively to improve adoption of our guidance by key organizations. Conclusion: Our international team will develop guidance for collaborator and partner engagement in health care evidence syntheses. Incorporating partnership values and expectations may result in better uptake, potentially reducing health inequities. [ABSTRACT FROM AUTHOR]

Background: Wagner's Chronic Care Model (CCM), as well as the expanded version (ECCM) developed by Barr and colleagues, have been widely adopted as frameworks for prevention and management of chronic disease. Given the high prevalence of chronic illness in older persons, these frameworks can play a valuable role in reorienting the health care system to better serve the needs of seniors. We aimed to identify and assess the measured goals of E/CCM interventions in older populations. In particular, our objective was to determine the extent to which published E/CCM initiatives were evaluated based on population, community, system and individual-level outcomes (including clinical, functional and quality of life measures).Methods: We conducted a systematic search of the Science Citation Index Web of Knowledge search tool to gather articles published between January 2003 and July 2014. We included published CCM interventions that cited at least one of the fundamental papers that introduced and described the CCM and ECCM. Studies retained for review reported evaluations of senior-focused E/CCM initiatives in community-based settings, with the topic of "older adults" OR senior* OR elder* OR geriatric OR aged. The resulting 619 published articles were independently reviewed for inclusion by two researchers. We excluded the following: systematic reviews, meta-analyses, descriptions of proposed programs, and studies whose populations did not focus on seniors.Results: We identified 14 articles that met inclusion criteria. Studies used a wide range of measures, with little consensus between studies. All of the included studies used the original CCM. While a range of system-level and individual patient outcomes have been used to evaluate CCM interventions, no studies employed measures of population or community health outcomes.Conclusions: Future efforts to test E/CCM interventions with seniors would be aided by more consistent outcome measures, greater attention to outcomes for the caregivers of older persons with chronic illness, and a greater focus on population and community impacts. [ABSTRACT FROM AUTHOR]

Background: The increasing prevalence of chronic disease faced by both developed and developing countries is of considerable concern to a number of international organisations. Many of the interventions to address this concern within primary healthcare settings are based on the chronic care model (CCM). The implementation of complex interventions such as CCMs requires careful consideration and planning. Success depends on a number of factors at the healthcare provider, team, organisation and system levels. Methods: The aim of this systematic review was to systematically examine the scientific literature in order to understand the facilitators and barriers to implementing CCMs within a primary healthcare setting. This review focused on both quantitative and qualitative studies which included patients with chronic disease (cardiovascular disease, chronic kidney disease, chronic respiratory disease, type 2 diabetes mellitus, depression and HIV/AIDS) receiving care in primary healthcare settings, as well as primary healthcare providers such as doctors, nurses and administrators. Papers were limited to those published in English between 1998 and 2013. Results: The search returned 3492 articles. The majority of these studies were subsequently excluded based on their title or abstract because they clearly did not meet the inclusion criteria for this review. A total of 226 full text articles were obtained and a further 188 were excluded as they did not meet the criteria. Thirty eight published peer-reviewed articles were ultimately included in this review. Five primary themes emerged. In addition to ensuring appropriate resources to support implementation and sustainability, the acceptability of the intervention for both patients and healthcare providers contributed to the success of the intervention. There was also a need to prepare healthcare providers for the implementation of a CCM, and to support patients as the way in which they receive care changes. Conclusion: This systematic review demonstrated the importance of considering human factors including the influence that different stakeholders have on the success or otherwise of the implementing a CCM. [ABSTRACT FROM AUTHOR]

Background: Providing high quality acute hospital care for patients with dementia is an increasing challenge as the prevalence of the disease rises. Informal carers of people with dementia are a critical resource for improving inpatient care, due to their insights into patients' needs and preferences. We summarise informal carers' perspectives of acute hospital care to inform best practice service delivery.Methods: We conducted a systematic search of bibliographic databases and sought relevant grey literature. We used thematic synthesis analysis to assimilate results of the studies and describe components of care that influence perceived quality.Results: Twenty papers met the inclusion criteria. Findings identified four overarching components of care that influenced carer experience and their perceptions of care quality: 'Patient care', 'Staff interactions', 'Carer's situation' and 'Hospital environment'. Need for improvement was identified in staff training, provision of help with personal care needs, and dignified treatment of patients. Carers need to be informed, involved and supported during hospital admission in order to promote the most positive experience.Conclusion: This review identifies common perspectives of informal carers of people with dementia in the acute hospital setting and highlights important areas to address to improve the experience of an admission for both carer and patient. [ABSTRACT FROM AUTHOR]

Background: Integrated reminders within clinical systems have become more prevalent due to the use of electronic health records and evidence demonstrating an increase in compliance within practice. Clinical reminders are assessed for effectiveness on an individual basis, rather than in combination with existing prompts for other conditions. The growing number of prompts may be counter-productive as healthcare professionals are increasingly suffering from "reminder fatigue" meaning many reminders are ignored. This work will review the qualitative evidence to identify barriers and enablers of existing prompts found within computerised decision support systems. Our focus will be on primary care where clinicians have to negotiate a plethora of reminders as they deal with increasingly complex patients and sophisticated treatment regimes. The review will provide a greater understanding of existing systems and the way clinicians interact with them to inform the development of more effective and targeted clinical reminders. Methods: A comprehensive search using piloted terms will be used to identify relevant literature from 1960 (or commencement of database) to 2017. MEDLINE, MEDLINE In Process, EMBASE, HMIC, PsycINFO, CDSR DARE, HTA, CINAHL and CPCI, will be searched, as well as grey literature and references and citations of included papers. Manuscripts will be assessed for eligibility, bias and quality using the CASP tool with narrative data being included and questionnaire based studies excluded. Inductive thematic analysis will be performed in order to produce a conceptual framework defining the key barriers around integrated clinical reminders. Discussion: Indications of alert and reminder fatigue are found throughout the current literature. However, this has not been fully investigated using a robust qualitative approach, particularly in a rapidly growing body of evidence. This review will aid people forming new clinical systems so that alerts can be incorporated appropriately. [ABSTRACT FROM AUTHOR]

Background: Healthcare systems are overloaded and changing. In response to growing demands on the healthcare systems, new models of healthcare delivery are emerging. Community paramedicine is a novel approach in which paramedics use their knowledge and skills beyond emergency health response to contribute to preventative and rehabilitative health. In our systematic review, we aimed to identify evidence of the community paramedicine role in care delivery for elderly patients, with an additional focus on palliative care, and the possible impact of this role on the wider healthcare system.Methods: A systematic review of peer-reviewed literature from MEDLINE, Embase, CINAHL, and Web of Sciences was undertaken to identify relevant full-text articles in English published until October 3, 2019. Additional inclusion criteria were studies focussing on extended care paramedics or community paramedics caring for elderly patients. Case studies were excluded. All papers were screened by at least two authors and underwent a quality assessment, using the Joanna Briggs Institute appraisal checklists for cross sectional, qualitative, cohort, and randomised controlled trial studies to assess the methodological quality of the articles. A process of narrative synthesis was used to summarise the data.Results: Ten studies, across 13 articles, provided clear evidence that Community Paramedic programs had a positive impact on the health of patients and on the wider healthcare system. The role of a Community Paramedic was often a combination of four aspects: assessment, referral, education and communication. Limited evidence was available on the involvement of Community Paramedics in palliative and end-of-life care and in care delivery in residential aged care facilities. Observed challenges were a lack of additional training, and the need for proper integration and understanding of their role in the healthcare system.Conclusions: The use of community paramedics in care delivery could be beneficial to both patients' health and the wider healthcare system. They already play a promising role in improving the care of our elderly population. With consistent adherence to the training curriculum and effective integration within the wider healthcare system, community paramedics have the potential to take on specialised roles in residential aged care facilities and palliative and end-of-life care. [ABSTRACT FROM AUTHOR]

Background: Poor retention in care and non-adherence to antiretroviral therapy (ART) continue to undermine the success of HIV treatment and care programmes across the world. There is a growing recognition that multifaceted interventions - application of two or more adherence-enhancing strategies - may be useful to improve ART adherence and retention in care among people living with HIV/AIDS. Empirical evidence shows that multifaceted interventions produce better results than interventions based on a singular perspective. Nevertheless, the bundle of mechanisms by which multifaceted interventions promote ART adherence are poorly understood. In this paper, we reviewed theories on ART adherence to identify candidate/potential mechanisms by which the adherence club intervention works.Methods: We searched five electronic databases (PubMed, EBSCOhost, CINAHL, PsycARTICLES and Google Scholar) using Medical Subject Headings (MeSH) terms. A manual search of citations from the reference list of the studies identified from the electronic databases was also done. Twenty-six articles that adopted a theory-guided inquiry of antiretroviral adherence behaviour were included for the review. Eleven cognitive and behavioural theories underpinning these studies were explored. We examined each theory for possible 'generative causality' using the realist evaluation heuristic (Context-Mechanism-Outcome) configuration, then, we selected candidate mechanisms thematically.Results: We identified three major sets of theories: Information-Motivation-Behaviour, Social Action Theory and Health Behaviour Model, which explain ART adherence. Although they show potential in explaining adherence bebahiours, they fall short in explaining exactly why and how the various elements they outline combine to explain positive or negative outcomes. Candidate mechanisms indentified were motivation, self-efficacy, perceived social support, empowerment, perceived threat, perceived benefits and perceived barriers. Although these candidate mechanisms have been distilled from theories employed to explore adherence to ART in various studies, the theories by themselves do not provide an explanatory model of adherence based on the realist logic.Conclusions: The identified theories and candidate mechanisms offer possible generative mechanisms to explain how and why patients adhere (or not) to antiretroviral therapy. The study provides crucial insights to understanding how and why multifaceted adherence-enhancing interventions work (or not). These findings have implications for eliciting programme theories of group-based adherence interventions such as the adherence club intervention. [ABSTRACT FROM AUTHOR]

Background: The recruitment of community health volunteers (CHVs) to support the delivery of health programmes is an established approach in underserved areas and in particular where there are health inequalities due to the scarcity of trained human resources. However, there is a dearth of evidence about what works to improve CHVs' performance. This review aimed to synthesise existing literature to explain why, how and under which circumstances intervention approaches to improve the performance of CHVs are more likely to be successful.Methods: We performed a realist synthesis. We identified candidate theories related to our review questions, which then guided the selection, appraisal and analysis of primary studies. Publications of interest dating from 2008 to 2012 were identified by a systematic search in PubMed and IDEAS databases. We considered all study designs that examined the various aspects of CHV performance in the context of formal organisational settings to be eligible and excluded the studies that did not provide explanation about the performance of CHVs neither in the findings nor in the discussion part. Data were arranged according to their reference to context, interventions, outcomes and mechanisms in order to identify the interaction between them. The synthesis of data allowed us to determine explanatory patterns within or across the studies.Results: We identified broad intervention approaches within the 23 papers included in the review: positioning of the CHV within the community, establishment of clear roles, provision of skill-based and ongoing training, incentives, supervision and logistical support for task distribution and implementation. The findings provided information regarding which mechanisms (self-esteem, sense of duty, self-efficacy, sense of being fairly treated) to target when implementing such approaches, and which contextual factors (stable and supportive cultural, political and social context and intervention closely linked to local health services) create the most favourable conditions for these mechanisms to occur, ultimately contributing to CHVs' better performance. Four main explanatory patterns around these mechanisms emerged as being fundamental to better performance.Conclusions: The patterns identified, combined with the designers' and other stakeholders' assumptions on how such interventions are expected to work, can be tested by empirical studies in order to provide useful information to be used by programme implementers, policymakers, donors and the community. [ABSTRACT FROM AUTHOR]

Background: Migrant families' transnational ties (i.e., connections to their countries of origin) may contribute to their hardships and/or may be a source of resiliency. A care approach that addresses these transnational ties may foster a positive identity and give coherence to experiences. We conducted an integrative review to determine what is known about transnational ties and the care of migrant families during pregnancy, postpartum and early childhood.Methods: We searched 15 databases to identify literature reporting on a health or social program, service, or care experience of migrant families during pregnancy up to age five in a Western country (i.e., Canada, US, Australia, New Zealand or a European country). Information regarding if and how the service/program/care considered transnational ties, and care-providers' perceptions of transnational ties, was extracted, analyzed and synthesized according to transnational 'ways of belonging' and 'ways of being'.Results: Over 34,000 records were screened; 69 articles were included. Care, programs and services examined included prenatal interventions (a mhealth app, courses, videos, and specialized antenatal care), doula support, maternity care, support groups, primary healthcare and psycho-social early intervention and early childhood programs. The results show that transnational ties in terms of 'ways of belonging' (cultural, religious and linguistic identity) are acknowledged and addressed in care, although important gaps remain. Regarding 'ways of being', including emotional, social, and economic ties with children and other family members, receipt of advice and support from family, and use of health services abroad, there is very little evidence that these are acknowledged and addressed by care-providers. Perceptions of 'ways of belonging' appear to be mixed, with some care-providers being open to and willing to adapt care to accommodate religious, cultural and linguistic differences, while others are not. How care-providers perceive the social, emotional and economic ties and/or the use of services back home, remains relatively unknown.Conclusion: Significant knowledge gaps remain regarding care-providers' perceptions of transnational 'ways of being' and whether and how they take them into account, which may affect their relationships with migrant families and/or the effectiveness of their interventions. Continued efforts are needed to ensure care is culturally safe for migrants. [ABSTRACT FROM AUTHOR]

Background: Out of pocket payments are the predominant method of financing healthcare in many developing countries, which can result in impoverishment and financial catastrophe for those affected. In 2010, WHO estimated that approximately 100 million people are pushed below the poverty line each year by payments for healthcare. Micro health insurance (MHI) has been used in some countries as means of risk pooling and reducing out of pocket health expenditure. A systematic review was conducted to assess the extent to which MHI has contributed to providing financial risk protection to low-income households in developing countries, and suggest how the findings can be applied in the Pakistani setting.Methods: We conducted a systematic search for published literature using the search terms "Community based health insurance AND developing countries", "Micro health insurance AND developing countries", "Mutual health insurance AND developing countries", "mutual OR micro OR community based health insurance" "Health insurance AND impact AND poor" "Health insurance AND financial protection" and "mutual health organizations" on three databases, Pubmed, Google Scholar and Science Direct (Elsevier). Only those records that were published in the last ten years, in English language with their full texts available free of cost, were considered for inclusion in this review. Hand searching was carried out on the reference lists of the retrieved articles and webpages of international organizations like World Bank, World Health Organization and International Labour Organization.Results: Twenty-three articles were eligible for inclusion in this systematic review (14 from Asia and 9 from Africa). Our analysis shows that MHI, in the majority of cases, has been found to contribute to the financial protection of its beneficiaries, by reducing out of pocket health expenditure, catastrophic health expenditure, total health expenditure, household borrowings and poverty. MHI also had a positive safeguarding effect on household savings, assets and consumption patterns.Conclusion: Our review suggests that MHI, targeted at the low-income households and tailored to suit the cultural and geographical structures in the various areas of Pakistan, may contribute towards providing protection to the households from catastrophe and impoverishment resulting from health expenditures. This paper emphasizes the need for further research to fill the knowledge gap that exists about the impact of MHI, using robust study designs and impact indicators. [ABSTRACT FROM AUTHOR]

Background: Rising cancer incidence, the cost of cancer pharmaceuticals and the introduction of the Cancer Drugs Fund in England, but not other United Kingdom(UK) countries means evidence of 'postcode prescribing' in cancer is important. There have been no systematic reviews considering access to cancer drugs by geographical characteristics in the UK.Methods: Studies describing receipt of cancer drugs, according to healthcare boundaries (e.g. cancer network [UK]) were identified through a systematic search of electronic databases and grey literature. Due to study heterogeneity a meta-analysis was not possible and a narrative synthesis was performed.Results: 8,780 unique studies were identified and twenty-six included following a systematic search last updated in 2015. The majority of papers demonstrated substantial variability in the likelihood of receiving chemotherapy between hospitals, health authorities, cancer networks and UK countries (England and Wales). After case-mix adjustment, there was up to a 4-5 fold difference in chemotherapy utilisation between the highest and lowest prescribing cancer networks. There was no strong evidence that rurality or distance travelled were associated with the likelihood of receiving chemotherapy and conflicting evidence for an effect of travel time.Conclusions: Considerable variation in chemotherapy prescribing between healthcare boundaries has been identified. The absence of associations with natural geographical characteristics (e.g. rurality) and receipt of chemotherapy suggests that local treatment habits, capacity and policy are more influential. [ABSTRACT FROM AUTHOR]

Background: Telemedicine represents an important strategy to facilitate access to medication abortion (MAB) procedures, reduces distance barriers and expands coverage to underserved communities. The aim is evaluating the self-managed MAB (provided through telemedicine as the sole intervention or in comparison to in-person care) in pregnant people at up to 12 weeks of pregnancy. Methods: A literature search was conducted using electronic databases: MEDLINE, Embase, Cochrane (Central Register of Controlled Trials and Database of Systematic Reviews), LILACS, SciELO, and Google Scholar. The search was based on the Population, Intervention, Comparison, Outcome, and Study Design (PICOS) framework, and was not restricted to any years of publication, and studies could be published in English or Spanish. Study screening and selection, risk of bias assessment, and data extraction were performed by peer reviewers. Risk of bias was evaluated with RoB 2.0 and ROBIS-I. A narrative and descriptive synthesis of the results was conducted. Meta-analyses with random-effects models were performed using Review Manager version 5.4 to calculate pooled risk differences, along with their individual 95% confidence intervals. The rate of evidence certainty was based on GRADE recommendations. Results: 21 articles published between 2011 and 2022 met the inclusion criteria. Among them, 20 were observational studies, and 1 was a randomized clinical trial. Regarding the risk of bias, 5 studies had a serious risk, 15 had a moderate risk, and 1 had an undetermined risk. In terms of the type of intervention, 7 compared telemedicine to standard care. The meta-analysis of effectiveness revealed no statistically significant differences between the two modalities of care (RD = 0.01; 95%CI 0.00, 0.02). Our meta-analyses show that there were no significant differences in the occurrence of adverse events or in patient satisfaction when comparing the two methods of healthcare delivery. Conclusion: Telemedicine is an effective and viable alternative for MAB, similar to standard care. The occurrence of complications was low in both forms of healthcare delivery. Telemedicine services are an opportunity to expand access to safe abortion services. Plain English summary: Globally, unsafe abortion causes 47,000 deaths and 5 million sexual and reproductive dysfunctions in young pregnant people due to complications of the procedure. This practice is related to barriers to accessing safe abortion services secondary to health system limitations and inequities in the distribution of resources. Telemedicine has proven to be an efficient care alternative to reduce distancing gaps, decrease waiting time and rationalize the costs derived from the procedure. Consequently, several health systems in the world use this model with differences in treatment schemes, weeks of gestation, pregnancy confirmation methods and measurement of reported outcomes. For this reason, evaluating the effectiveness and safety of self-managed medication abortion (MAB) by telemedicine is a support for decision makers who consider implementing or expanding remote care services. This systematic review integrated studies that evaluated MAB only by Telemedicine or in comparison with standard care on pregnant people with 12 weeks gestation or less. Available studies until January 2023 were chosen. Screening and selection of studies, data extraction, and risk of bias assessment were performed by expert reviewers. Aspects such as the effectiveness, safety, and satisfaction of the procedure, among other outcomes, were reviewed. A narrative and descriptive synthesis was carried out, as well as several meta-analyses of the differences in risks between Telemedicine and in-person care. The meta-analysis of studies comparing telemedicine care with standard services reveals that the type of care provided does not affect the effectiveness and safety of MAB, nor does it affect user satisfaction, follow-up, or medication adherence. [ABSTRACT FROM AUTHOR]

Introduction: Aboriginal Health and Wellbeing staff are crucial for successful primary health care for Aboriginal communities. However, they are often affected by high rates of stress, burnout, and staff turn-over, which can impact primary health care delivery to Aboriginal peoples. The aim of this review was to identify organisational factors that help support the retention of Aboriginal Health and Wellbeing staff in Aboriginal Health services. Methods: A comprehensive literature review was undertaken. Eleven electronic databases were searched for papers published between 2002 and 2017 and supplemented by hand searching. Papers were included if they were in English, full text, peer-reviewed, and had a focus on retention of Aboriginal Health and Wellbeing staff, or health staff in comparable roles working in Aboriginal health services. Twenty-six papers were included in the final review. Results: Five key themes were identified as being important to the retention of Aboriginal Health and Wellbeing staff in Aboriginal Health Services: feeling culturally safe and secure within the workplace; teamwork and collaboration; supervision and strong managerial leadership and support from peers (to debrief, reflect, receive emotional support and strengthen coping mechanisms); professional development (the opportunity for skill development and role progression); and recognition (of work load, quality of work performed, being trusted to work autonomously, and financial remuneration that reflected the high pressure of the role). Conclusion: Aboriginal Health and Wellbeing staff are fundamental to successful primary health care for Aboriginal peoples. State and Federal Governments should consider formalising recognition of the significant cultural knowledge that Aboriginal Health and Wellbeing staff bring to their roles. Formal recognition could also pave the way to revise remuneration as well as ensure adequate support mechanisms are put in place to improve retention and reduce stress and burnout affecting Aboriginal Health and Wellbeing staff. [ABSTRACT FROM AUTHOR]

Background: This paper reports the methods and findings from a systematic review of economic evaluations conducted in the community aged care sector between 2000 and 2016.Methods: Online databases searched were PubMed, Medline, Scopus, and web of science, CINAHL and informit. Studies were included if they 1) were full economic evaluations that compared both the costs and outcomes of two or more interventions 2) in study population of people aged 65 years and over 3) dependent older people living in the community 4) alternatives being compared were care models or service delivery interventions in the community aged care sector (a group of programs that have been established as a support system to allow older people to remain living in their own homes for as long as possible, as an alternative to institutional or residential care) and 5) published in the English language between 2000 and November 2016.Results: Eleven studies reporting upon economic evaluations of service delivery interventions in community aged care were identified; the majority of which were undertaken in Europe. Critical appraisal of the identified studies highlighted the methodological rigour in these evaluations.Conclusion: This systematic review highlights the paucity of economic evaluation studies conducted to date in the community aged care sector. The findings highlight the importance of cost utility analysis methodology as it allows for a uniform outcome measure, that facilitates the comparison of different interventions. In addition, multi-attribute utility measures that represent those quality of life domains that are most important to older people should be used and attention must be paid to the inclusion of informal care costs and outcomes as this is a key resource in community aged care service delivery. [ABSTRACT FROM AUTHOR]

Background: There is an increasing recognition that non communicable diseases impose large economic costs on households, societies and nations. However, not much is known about the magnitude of diabetes expenditure in African countries and to the best of our knowledge no systematic assessment of the literature on diabetes costs in Africa has been conducted. The aim of this paper is to capture the evidence on the cost of diabetes in Africa, review the methods used to calculate costs and identify areas for future research.Methods: A desk search was conducted in Pubmed, Medline, Embase, and Science direct as well as through other databases, namely Google Scholar. The following eligibility criteria were used: peer reviewed English articles published between 2006 and 2016, articles that reported original research findings on the cost of illness in diabetes, and studies that covered at least one African country. Information was extracted using two data extraction sheets and results organized in tables. Costs presented in the studies under review are converted to 2015 international dollars prices (I$).Results: Twenty six articles are included in this review. Annual national direct costs of diabetes differed between countries and ranged from I$3.5 billion to I$4.5 billion per annum. Indirect costs per patient were generally higher than the direct costs per patient of diabetes. Outpatient costs varied by study design, data source, perspective and healthcare cost categories included in the total costs calculation. The most commonly included healthcare items were drug costs, followed by diagnostic costs, medical supply or disposable costs and consultation costs. In studies that reported both drug costs and total costs, drug costs took a significant portion of the total costs per patient. The highest burden due to the costs associated with diabetes was reported in individuals within the low income group.Conclusion: Estimation of the costs associated with diabetes is crucial to make progress towards meeting the targets laid out in Sustainable Development Goal 3 set for 2030. The studies included in this review show that the presence of diabetes leads to elevated costs of treatment which further increase in the presence of complications. The cost of drugs generally contributed the most to total direct costs of treatment. Various methods are used in the estimation of diabetes healthcare costs and the costs estimated between countries differ significantly. There is room to improve transparency and make the methodologies used standard in order to allow for cost comparisons across studies. [ABSTRACT FROM AUTHOR]

Background: Abu Dhabi is the capital of the United Arab Emirates (UAE) and the largest of the seven emirates in terms of land mass and population. Abu Dhabi emirate has three different geographical regions: the Central Capital District, the Eastern Region, and the Western Region. The health system has been regulated by the Health Authority - Abu Dhabi (HAAD), and has been provided by the Abu Dhabi Health Services Company (SEHA), since 2007. The UAE has a high population-burden of morbidity and mortality related to chronic diseases. This paper aims to characterize the Primary Health Care (PHC) public services in Abu Dhabi using the Chronic Care Model (CCM) as a framework.Methods: Officially published data from HAAD, SEHA and the UAE Ministry of Health and Prevention was reviewed and abstracted. The Preferred Reporting Items Systematic Reviews and Meta-Analysis (PRISMA) statement was used as a baseline to review the PHC services through the CCM approach and to identify potential opportunities for improvement.Results: There are 38 SEHA Ambulatory Healthcare Centers (AHS) that provide PHC, from which 20 are located in the Eastern Region and the other 18 in the Central Capital District. The AHS adopted the principles of the patient-centered medical home model, aiming at providing structured, proactive and coordinated care. Implementation of the CCM elements aligns with those standards and is positively associated with the use of interventions targeting high-risk behaviors.Conclusion: The UAE has a strong foundation in place for addressing the growing problem of chronic diseases. The CCM has been shown to have beneficial effects on clinical outcomes reinforcing the PHC procedures and processes of care and should continue to inform systematic efforts to improve the care that lead to better lives for the Abu Dhabi community. [ABSTRACT FROM AUTHOR]

Background: Improving the ethical competencies of nursing students, as an important dimension of professional competence, is a primary objective of nursing education. Thus, this study aimed to explore a guide for codes of ethics for the development of ethical competence among nursing students in the healthcare system of Iran. Methods: This is a systematic review and meta-synthesis of qualitative studies conducted in the healthcare system of Iran. The review included studies published between January 1, 2000 and March 2024. We conducted a comprehensive search in various international and national databases, including Web of Science, PubMed, Embase, PsycINFO, Cochrane Library, CINAHL, Scopus, Barakatns, MagIran and SID. Initially, 86 qualitative studies were identified, and after a meticulous screening process, 39 studies were carefully reviewed. Finally, 10 qualitative studies were selected for analysis. The meta-synthesis employed an interpretive approach by thematic synthesis. Results: Based on our results, four main themes and 10 categories, along with summarized codes, were extracted as crucial elements of the codes of ethics for the professional competence of Iranian nursing students. The main themes identified were knowledge, standards, experiences, and attitudes (KSEA). Conclusions: The concept of codes of ethics for developing professional competencies in Iranian nursing students was detected as a multidimensional concept with four major areas. By emphasizing the rights of clients and the standardization of nursing practice, this set of ethical codes can contribute to preventing clinical errors and legal issues at hospitals and educational settings. Furthermore, it fosters a positive environment that encourages professional behaviors among nursing students. Nursing students, as future nurses, should apply codes of ethics when facing emerging ethical challenges. Nurse educators have a crucial role in providing students with the necessary preparation and guidance during their professional socialization process in nursing schools. [ABSTRACT FROM AUTHOR]

Background: Despite significant progress in cardiovascular disease (CVD) management, it remains a public health priority and a global challenge. Within the disease process, health care after a cardiovascular event (secondary prevention) is essential to prevent recurrences. Nonetheless, evidence has suggested the existence of gender disparities in CVD management, leaving women in a vulnerable situation. The objective of this study is to identify all available evidence on the existence of gender differences in health care attention after a major adverse cardiovascular event. Methods: A scoping review following the structure of PRISMA-ScR was conducted. To define the inclusion criteria, we used Joanna Briggs Institute (JBI) population, concept, context framework for scoping reviews. A systematic search was performed in MEDLINE (PubMed), EMBASE and Cochrane. The methods of this review are registered in the International Platform of Registered Systematic Review and Meta-Analysis Protocols (INPLASY) (INPLASY202350084). Results: The initial search retrieved 3,322 studies. 26 articles were identified manually. After the reviewing process, 93 articles were finally included. The main intervention studied was the pharmacological treatment received (n = 61, 66%), distantly followed by guideline-recommended care (n = 26, 28%) and cardiac rehabilitation (CR) referral (n = 16)". Literature described gender differences in care and management of secondary prevention of CVD. Women were less frequently treated with guideline-recommended medications and seem more likely to be non-adherent. When analysing guideline recommendations, women were more likely to make dietary changes, however, men were more likely to increase physical activity. Studies also showed that women had lower rates of risk factor testing and cholesterol goals attainment. Female sex was associated with lower rates of cardiac rehabilitation referral and participation. Conclusions: This review allowed us to compile knowledge on the existence of gender inequalities on the secondary prevention of CVD. Additional research is required to delve into various factors influencing therapeutic disparities, referral and non-participation in CR programs, among other aspects, in order to improve existing knowledge about the management and treatment of CVD in men and women. This approach is crucial to ensure the most equitable and effective attention to this issue. [ABSTRACT FROM AUTHOR]

Background: There is some evidence that differentiated service delivery (DSD) models, which use a client-centered approach to simplify and increase access to care, improve clinical outcomes among people living with HIV (PLHIV) in high HIV prevalence countries. Integrating economic strengthening tools (e.g., microcredit, cash transfers, food assistance) within DSD models can help address the poverty-related barriers to HIV antiretroviral therapy (ART). Yet there is minimal evidence of the cost-effectiveness of these types of multilevel care delivery models, which potentially prohibits their wider implementation. Methods: Using a qualitative systematic review, this article synthesizes the literature surrounding the cost-effectiveness of differentiated service delivery models that employ economic strengthening initiatives to improve HIV treatment adherence in low- and middle-income countries. We searched three academic databases for randomized controlled trials and observational studies published from January 2000 through March 2024 in Sub-Saharan Africa. The quality of each study was scored using a validated appraisal system. Results: Eighty-nine full texts were reviewed and 3 met all eligibility criteria. Two of the three included articles were specific to adolescents living with HIV. Economic strengthening opportunities varied by care model, and included developmental savings accounts, microenterprise workshops, and cash and non-cash conditional incentives. The main drivers of programmatic and per-patient costs were ART medications, CD4 cell count testing, and economic strengthening activities. Conclusion: All economic evaluations in this review found that including economic strengthening as part of comprehensive differentiated service delivery was cost-effective at a willingness to pay threshold of at least 2 times the national per capita gross domestic product. Two of the three studies in this review focused on adolescents, suggesting that these types of care models may be especially cost-effective for youth entering adulthood. All studies were from the provider perspective, indicating that additional evidence is needed to inform the potential cost-savings of DSD and economic strengthening interventions to patients and society. Randomized trials testing the effectiveness of DSD models that integrate economic strengthening should place greater emphasis on costing these types of programs to inform the potential for bringing these types of multilevel interventions to scale. [ABSTRACT FROM AUTHOR]

Background: Racism in the healthcare system has become a burgeoning focus in health policy-making and research. Existing research has shown both interpersonal and structural forms of racism limiting access to quality healthcare for racialised healthcare users. Nevertheless, little is known about the specifics of racism in the inpatient sector, specifically hospitals and rehabilitation facilities. The aim of this scoping review is therefore to map the evidence on racial discrimination experienced by people receiving treatment in inpatient settings (hospitals and rehabilitation facilities) or their caregivers in high-income countries, focusing specifically on whether intersectional axes of discrimination have been taken into account when describing these experiences. Methods: Based on the conceptual framework developed by Arksey and O'Malley, this scoping review surveyed existing research on racism and racial discrimination in inpatient care in high-income countries published between 2013 and 2023. The software Rayyan was used to support the screening process while MAXQDA was used for thematic coding. Results: Forty-seven articles were included in this review. Specifics of the inpatient sector included different hospitalisation, admission and referral rates within and across hospitals; the threat of racial discrimination from other healthcare users; and the spatial segregation of healthcare users according to ethnic, religious or racialised criteria. While most articles described some interactions between race and other social categories in the sample composition, the framework of intersectionality was rarely considered explicitly during analysis. Discussion: While the USA continue to predominate in discussions, other high-income countries including Canada, Australia and the UK also examine racism in their own healthcare systems. Absent from the literature are studies from a wider range of European countries as well as of racialised and disadvantaged groups other than refugees or recent immigrants. Research in this area would also benefit from an engagement with approaches to intersectionality in public health to produce a more nuanced understanding of the interactions of racism with other axes of discrimination. As inpatient care exhibits a range of specific structures, future research and policy-making ought to consider these specifics to develop targeted interventions, including training for non-clinical staff and robust, transparent and accessible complaint procedures. [ABSTRACT FROM AUTHOR]

Background: The United Arab Emirates (UAE) government aspires to build a world class health system to improve the quality of healthcare and the health outcomes for its population. To achieve this it has implemented extensive health system reforms in the past 10 years. The nature, extent and success of these reforms has not recently been comprehensively reviewed. In this paper we review the progress and outcomes of health systems reform in the UAE.Methods: We searched relevant databases and other sources to identify published and unpublished studies and other data available between 01 January 2002 and 31 March 2016. Eligible studies were appraised and data were descriptively and narratively synthesized.Results: Seventeen studies were included covering the following themes: the UAE health system, population health, the burden of disease, healthcare financing, healthcare workforce and the impact of reforms. Few, if any, studies prospectively set out to define and measure outcomes. A central part of the reforms has been the introduction of mandatory private health insurance, the development of the private sector and the separation of planning and regulatory responsibilities from provider functions. The review confirmed the commitment of the UAE to build a world class health system but amongst researchers and commentators opinion is divided on whether the reforms have been successful although patient satisfaction with services appears high and there are some positive indications including increasing coverage of hospital accreditation. The UAE has a rapidly growing population with a unique age and sex distribution, there have been notable successes in improving child and maternal mortality and extending life expectancy but there are high levels of chronic diseases. The relevance of the reforms for public health and their impact on the determinants of chronic diseases have been questioned.Conclusions: From the existing research literature it is not possible to conclude whether UAE health system reforms are working. We recommend that research should continue in this area but that research questions should be more clearly defined, focusing whenever possible on outcomes rather than processes. [ABSTRACT FROM AUTHOR]

Background: Tyrosinemia type 1 (TYR1) is a rare autosomal recessive disorder of amino acid metabolism that is fatal without treatment. With medication (nitisinone) and dietary restrictions outcomes are improved. We conducted a systematic review to investigate if treatment with nitisinone following screening provides better long-term outcomes than treatment with nitisinone following symptomatic detection.Methods: We searched Web of Science, Medline, Pre-Medline, and Embase up to 23rd September 2016 for journal articles comparing clinical outcomes of TYR1 patients receiving earlier versus later nitisinone treatment. Two reviewers independently screened titles and abstracts, assessed full texts, and appraised study quality. Data extraction was performed by a single reviewer and checked by a second.Results: We included seven articles out of 470 unique records identified by our search. The seven articles included four studies (three cohort studies and one cross-sectional study). Study sample sizes ranged from 17 to 148. There is consistent evidence that nitisinone is an effective treatment for TYR1, and some evidence that earlier treatment with nitisinone and dietary restrictions within the first one or 2 months of life is associated with reduced need for liver transplantation, lower rates of renal dysfunction, fewer neurological crises, and fewer, shorter hospital admissions compared to later treatment. However, study quality was moderate to weak, with high risk of confounding and applicability concerns to the screening context. We conducted post hoc analyses to address these issues. Results suggested an association between earlier treatment and fewer liver transplants (earlier treatment: 0% of 10-24 patients; later treatment: 25-60% of 4-15 patients), but no impact on neurological crises. We found no effect of treatment timing on mortality in either the primary or post hoc analyses. Post hoc analyses of other health-related outcomes were not possible because of sample size or reporting.Conclusions: There is some evidence from observational studies that earlier treatment with nitisinone might be beneficial but this is subject to bias. The applicability of our findings to the screening context or clinical practice is limited as not all early-treated patients were identified by screening and late-treated groups included patients born prior to the availability of nitisinone. [ABSTRACT FROM AUTHOR]

Background: Successful models of nursing and midwifery in the community delivering healthcare throughout the lifespan and across a health and illness continuum are limited, yet necessary to guide global health services. Primary and community health services are the typical points of access for most people and the location where most care is delivered. The scope of primary healthcare is complex and multifaceted and therefore requires a practice framework with sound conceptual and theoretical underpinnings. The aim of this paper is to present a conceptual model informed by a scoping evidence review of the literature. Methods: A scoping evidence review of the literature was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Databases included CINAHL, MEDLINE, PsycINFO and SocINDEX using the EBSCO platform and the Cochrane Library using the keywords: model, nursing, midwifery, community, primary care. Grey literature for selected countries was searched using the Google 'advanced' search interface. Data extraction and quality appraisal for both empirical and grey literature were conducted independently by two reviewers. From 127 empirical and 24 non-empirical papers, data extraction parameters, in addition to the usual methodological features, included: the nature of nursing and midwifery; the population group; interventions and main outcomes; components of effective nursing and midwifery outcomes. Results: The evidence was categorised into six broad areas and subsequently synthesised into four themes. These were not mutually exclusive: (1) Integrated and Collaborative Care; (2) Organisation and Delivery of Nursing and Midwifery Care in the Community; (3) Adjuncts to Nursing Care and (4) Overarching Conceptual Model. It is the latter theme that is the focus of this paper. In essence, the model depicts a person/client on a lifespan and preventative-curative trajectory. The health related needs of the client, commensurate with their point position, relative to both trajectories, determines the nurse or midwife intervention. Consequently, it is this need, that determines the discipline or speciality of the nurse or midwife with the most appropriate competencies. Conclusion: Use of a conceptual model of nursing and midwifery to inform decision-making in primary/ community based care ensures clinical outcomes are meaningful and more sustainable. Operationalising this model for nursing and midwifery in the community demands strong leadership and effective clinical governance. [ABSTRACT FROM AUTHOR]

Background: In Nigeria, several challenges have been reported within the health sector, especially in training, funding, employment, and deployment of the health workforce. We aimed to review recent health workforce crises in the Nigerian health sector to identify key underlying causes and provide recommendations toward preventing and/or managing potential future crises in Nigeria.Methods: We conducted a scoping literature search of PubMed to identify studies on health workforce and health governance in Nigeria. A critical analysis, with extended commentary, on recent health workforce crises (2010-2016) and the health system in Nigeria was conducted.Results: The Nigerian health system is relatively weak, and there is yet a coordinated response across the country. A number of health workforce crises have been reported in recent times due to several months' salaries owed, poor welfare, lack of appropriate health facilities and emerging factions among health workers. Poor administration and response across different levels of government have played contributory roles to further internal crises among health workers, with different factions engaged in protracted supremacy challenge. These crises have consequently prevented optimal healthcare delivery to the Nigerian population.Conclusions: An encompassing stakeholders' forum in the Nigerian health sector remain essential. The national health system needs a solid administrative policy foundation that allows coordination of priorities and partnerships in the health workforce and among various stakeholders. It is hoped that this paper may prompt relevant reforms in health workforce and governance in Nigeria toward better health service delivery in the country. [ABSTRACT FROM AUTHOR]

Background: The lack of proven efficacy of new healthcare interventions represents a problem for health systems globally. It is partly related to suboptimal implementation processes, leading to poor adoption of new interventions. Activation of Stratification Strategies and Results of the interventions on frail patients of Healthcare Services (ASSEHS) EU project (N° 2013 12 04) aims to study current existing health Risk Stratification (RS) strategies and tools on frail elderly patients. This paper aims at identifying variables that make the implementation of population RS tools feasible in different healthcare services.Methods: Two different methods have been used to identify the key elements in stratification implementation; i) a Scoping Review, in order to search and gather scientific evidence and ii) Semi-structured interviews with six key experts that had been actively involved in the design and/or implementation of RS strategies. It aims to focus the implementation construct on real-life contextual understandings, multi-level perspectives, and cultural influences.Results: A Feasibility Framework has been drawn. Two dimensions impact the feasibility of RS: (i) Planning, deployment and change management and (ii) Care intervention. The former comprises communication, training and mutual learning, multidisciplinarity of the team, clinicians' engagement, operational plan and ICT display and functionalities. The latter includes case finding and selection of the target population, pathway definition and quality improvement process.Conclusions: The Feasibility Framework provides a list of key elements that should be considered for an effective implementation of population risk stratification interventions. It helps to identify, plan and consider relevant elements to ensure a proper RS implementation. [ABSTRACT FROM AUTHOR]

Background: Health interventions fall along a spectrum from simple to more complex. There is wide interest in methods for reviewing 'complex interventions', but few transparent approaches for assessing intervention complexity in systematic reviews. Such assessments may assist review authors in, for example, systematically describing interventions and developing logic models. This paper describes the development and application of the intervention Complexity Assessment Tool for Systematic Reviews (iCAT_SR), a new tool to assess and categorise levels of intervention complexity in systematic reviews.Methods: We developed the iCAT_SR by adapting and extending an existing complexity assessment tool for randomized trials. We undertook this adaptation using a consensus approach in which possible complexity dimensions were circulated for feedback to a panel of methodologists with expertise in complex interventions and systematic reviews. Based on these inputs, we developed a draft version of the tool. We then invited a second round of feedback from the panel and a wider group of systematic reviewers. This informed further refinement of the tool.Results: The tool comprises ten dimensions: (1) the number of active components in the intervention; (2) the number of behaviours of recipients to which the intervention is directed; (3) the range and number of organizational levels targeted by the intervention; (4) the degree of tailoring intended or flexibility permitted across sites or individuals in applying or implementing the intervention; (5) the level of skill required by those delivering the intervention; (6) the level of skill required by those receiving the intervention; (7) the degree of interaction between intervention components; (8) the degree to which the effects of the intervention are context dependent; (9) the degree to which the effects of the interventions are changed by recipient or provider factors; (10) and the nature of the causal pathway between intervention and outcome. Dimensions 1-6 are considered 'core' dimensions. Dimensions 7-10 are optional and may not be useful for all interventions.Conclusions: The iCAT_SR tool facilitates more in-depth, systematic assessment of the complexity of interventions in systematic reviews and can assist in undertaking reviews and interpreting review findings. Further testing of the tool is now needed. [ABSTRACT FROM AUTHOR]

Background: Acute kidney injury (AKI) is a common complication in the critically ill patients and associated with a substantial morbidity and mortality. Severe AKI may be associated with up to 60% hospital mortality. Over the years, renal replacement therapy (RRT) has emerged as the mainstay of the treatment for AKI. However, the exact timing of initiation of RRT for better patient outcome is still debatable with conflicting data from randomized controlled trials. Thus, a systematic review and meta-analysis was performed to assess the impact of "early" versus "late" initiation of RRT.Methods: All the published literature through the major databases including Medline/Pubmed, Embase, and Google Scholar were searched from 1970 to October 2016. Reference lists from the articles were reviewed to identify additional pertinent articles. Retrieved papers concerning the effect of "early/prophylactic" RRT versus "late/as and when required" RRT were reviewed by the authors, and the data were extracted using a standardized data collection tool. Randomized trials (RCTs) comparing early initiation of RRT or prophylactic RRT with late or as and when required RRT were included. The primary outcome measures were all cause mortality and dialysis dependence on day 90. The secondary outcome measures were: length of ICU stay, length of hospital stay, recovery of renal function and adverse events.Results: Of the 547 citation retrieved, full text of 44 articles was assessed for eligibility. Of these a total of 10 RCTs with 1,636 participants were included. All the trials were open label; six trials have unclear or high risk of bias for allocation concealment while four trials have low risk of bias for allocation concealment. There was a variable definition of early versus late in different studies. Thus, the definition of early or late was taken according to individual study definition. Compared to late RRT, there was no significant benefit of early RRT on day 30 mortality [6 studies; 1301 participants; RR, 0.92;95% CI: 0.76, 1.12); day 60 mortality [3 trials;1075 participants; RR, 0.94; 95% CI: 0.78, 1.14)]; day 90 mortality [3 trials; 555 participants; RR,0.94;95% CI: 0.67, 1.33)]; overall ICU or hospital mortality; dialysis dependence on day 90 [3 trials; (RR, 1.06; 95% CI:0.53, 2.12)]. There was no significant difference between length of ICU or hospital stay or recovery of renal functions. A subgroup analysis based on modality of RRT or mixed medical and surgical vs. surgical or based on severity of illness showed no difference in outcome measure. The trials with high or unclear risk of bias for allocation concealment showed benefit of early RRT (RR, 0.74; 95% CI: 0.59, 0.91) while the trials with low risk of bias for allocation concealment showed no difference in the mortality (RR, 1.02; 95% CI: 0.89, 1.17). Grade evidence generated for most of the outcomes was "low quality".Conclusion: This updated meta-analysis showed no added benefit of early initiation of RRT for patients with AKI. The grade evidence generated was of "low quality" and there was a high heterogeneity in the included trials.Prospero Registration Number: CRD42016043092 . [ABSTRACT FROM AUTHOR]