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Background: Adult obesity rates in the United States have reached epidemic proportions, yet vary considerably across states and counties. We sought to explore community-level factors that may be associated with reduced adult obesity rates at the county level. Methods: We identified six U.S. counties that were positive deviants for adult obesity and conducted semistructured interviews with community leaders and government officials involved in efforts to promote healthier lifestyles. Using site visits and in-depth qualitative interviews, we identified several recurrent themes and strategies. Results: Participants: 1) developed a nuanced understanding of their communities; 2) recognized the complex nature of obesity, and 3) implemented a county-wide strategic approach for promoting healthy living. This county-wide approachwas used to a) break down silos and build partnerships, b) access community resources and connections, and c) transfer ownership to community members. Conclusions: We found that county leaders focused on establishing a county-wide structure to connect and support community-led initiatives to promote healthy living, reduce obesity, and foster sustainability. Findings from this study can help inform county-level efforts to improve healthy living and combat the multi-faceted challenges of adult obesity across the U.S. [ABSTRACT FROM AUTHOR]

Background: Hospital quality improvement efforts absorb substantial time and resources, but many innovations fail to integrate into organizational routines, undermining the potential to sustain the new practices. Despite a well-developed literature on the initial implementation of new practices, we have limited knowledge about the mechanisms by which integration occurs.Methods: We conducted a qualitative study using a purposive sample of hospitals that participated in the State Action on Avoidable Rehospitalizations (STAAR) initiative, a collaborative to reduce hospital readmissions that encouraged members to adopt new practices. We selected hospitals where risk-standardized readmission rates (RSRR) had improved (n = 7) or deteriorated (n = 3) over the course of the first 2 years of the STAAR initiative (2010-2011 to 2011-2012) and interviewed a range of staff at each site (90 total). We recruited hospitals until reaching theoretical saturation. The constant comparative method was used to conduct coding and identification of key themes.Results: When innovations were successfully integrated, participants consistently reported that a small number of key staff held the innovation in place for as long as a year while more permanent integrating mechanisms began to work. Depending on characteristics of the innovation, one of three categories of integrating mechanisms eventually took over the role of holding new practices in place. Innovations that proved intrinsically rewarding to the staff, by making their jobs easier or more gratifying, became integrated through shifts in attitudes and norms over time. Innovations for which the staff did not perceive benefits to themselves were integrated through revised performance standards if the innovation involved complex tasks and through automation if the innovation involved simple tasks.Conclusions: Hospitals have an opportunity to promote the integration of new practices by planning for the extended effort required to hold a new practice in place while integration mechanisms take hold. By understanding how integrating mechanisms correspond to innovation characteristics, hospitals may be able to foster integrating mechanisms most likely to work for particular innovations. [ABSTRACT FROM AUTHOR]

Background: Despite the potential for electronic health records (EHRs) to improve patient safety and quality of care, the intended benefits of EHRs are not always realized because of implementation-related challenges. Enlisting clinician super users to provide frontline support to employees has been recommended to foster EHR implementation success. In some instances, their enlistment has been associated with implementation success; in other cases, it has not. Little is known about why some super users are more effective than others. The purpose of this study was to identify super users' mechanisms of influence and examine their effects on EHR implementation outcomes. Methods: We conducted a longitudinal (October 2012 - June 2013), comparative case study of super users' behaviors on two medical units of a large, academic hospital implementing a new EHR system. We assessed super users' behaviors by observing 29 clinicians and conducting 24 in-depth interviews. The implementation outcome, clinicians' information systems (IS) proficiency, was assessed using longitudinal survey data collected from 43 clinicians before and after the EHR start-date. We used multivariable linear regression to estimate the relationship between clinicians' IS proficiency and the clinical unit in which they worked. Results: Super users on both units employed behaviors that supported and hindered implementation. Four super user behaviors differed between the two units: proactivity, depth of explanation, framing, and information-sharing. The unit in which super users were more proactive, provided more comprehensive explanations for their actions, used positive framing, and shared information more freely experienced significantly greater improvement in clinicians' IS proficiency (p =0.03). Use of the four behaviors varied as a function of super users' role engagement, which was influenced by how the two units' managers selected super users and shaped the implementation climate. Conclusions: Super users' behaviors in implementing EHRs vary substantively and can have important influence on implementation success. [ABSTRACT FROM AUTHOR]

Background: Improving outcomes for patients with acute myocardial infarction (AMI) is a priority for hospital leadership, clinicians, and policymakers. Evidence suggests links between hospital organizational culture and hospital performance; however, few studies have attempted to shift organizational culture in order to improve performance, fewer have focused on patient outcomes, and none have addressed mortality for patients with AMI. We sought to address this gap through a novel longitudinal intervention study, Leadership Saves Lives (LSL). Methods: This manuscript describes the methodology of LSL, a 2-year intervention study using a concurrent mixed methods design, guided by open systems theory and the Assess, Innovate, Develop, Engage, Devolve (AIDED) model of diffusion, implemented in 10 U.S. hospitals and their peer hospital networks. The intervention has three primary components: 1) annual convenings of the ten intervention hospitals; 2) semiannual workshops with guiding coalitions at each hospital; and 3) continuous remote support across all intervention hospitals through a web-based platform. Primary outcomes include 1) shifts in key dimensions of hospital organizational culture associated with lower mortality rates for patients with AMI; 2) use of targeted evidence-based practices associated with lower mortality rates for patients with AMI; and 3) in-hospital AMI mortality. Quantitative data include annual surveys of guiding coalition members in the intervention hospitals and peer network hospitals. Qualitative data include in-person, in-depth interviews with all guiding coalition members and selective observations of key interactions in care for patients with AMI, collected at three time points. Data integration will identify patterns and major themes in change processes across all intervention hospitals over time. Conclusions: LSL is novel in its use of a longitudinal mixed methods approach in a diverse sample of hospitals, its focus on objective outcome measures of mortality, and its examination of changes not only in the intervention hospitals but also in their peer hospital networks over time. This paper adds to the methodological literature for the study of complex interventions to promote hospital organizational culture change. [ABSTRACT FROM AUTHOR]

Background: Survival rates after acute myocardial infarction (AMI) vary markedly across U.S. hospitals. Although substantial efforts have been made to improve hospital performance, we lack contemporary evidence about changes in hospital strategies and features of organizational culture that might contribute to reducing hospital AMI mortality rates. We sought to describe current use of several strategies and features of organizational culture linked to AMI mortality in a national sample of hospitals and examine changes in use between 2010 and 2013. Methods: We conducted a cross-sectional survey of 543 hospitals (70% response rate) in 2013, and longitudinal analysis of a subsample of 107 hospitals that had responded to a survey in 2010 (67% response rate). Results: Between 2010 and 2013, the use of many strategies increased, but the use of only two strategies increased significantly: the percentage of hospitals providing regular training to Emergency Medical Service (EMS) providers about AMI care increased from 36% to 71% (P-value < 0.001) and the percentage of hospitals using computerized assisted physician order entry more than doubled (P-value < 0.001). Most, but not all, hospitals reported having environments conducive to communication, coordination and problem solving. Conclusions: We found few significant changes between 2010 and 2013 in hospital strategies or in key features of organizational culture that have been associated with lower AMI mortality rates. Findings highlight several opportunities to help close remaining performance gaps in AMI mortality among hospitals. [ABSTRACT FROM AUTHOR]

Background Decentralization through the establishment of hospital governing boards has been touted as an effective way to improve the quality and efficiency of hospitals in low-income countries. Although several studies have examined the process of decentralization, few have quantitatively assessed the implementation of hospital governing boards and their impact on hospital performance. Therefore, we sought to describe the functioning of governing boards and to determine the association between governing board functioning and hospital performance. Methods We conducted a cross-sectional study with governing board chairpersons to assess board (1) structure, (2) roles and responsibilities and (3) training and orientation practices. Using bivariate analysis and multivariable regression, we examined the association between governing board functioning and hospital performance. Hospital performance indicators: 1) percent of hospital management standards met, measured with the Ethiopian Hospital Reform Implementation Guidelines and 2) patient experience, measured with the Inpatient and Outpatient Assessment of Healthcare surveys. Results A total of 92 boards responded to the survey (96% response rate). The average percentage of EHRIG standards met was 58.1% (standard deviation (SD) 21.7 percentage points), and the mean overall patient experience score was 7.2 (SD 2.2). Hospitals with greater hospital management standards met had governing boards that paid members, reviewed performance in several domains quarterly or more frequently, developed new revenue sources, determined services to be outsourced, reviewed patient complaints, and had members with knowledge in business and financial management (all P-values < 0.05). Hospitals with more positive patient experience had governing boards that developed new revenue sources, determined services to be outsourced, and reviewed patient complaints (all P-values < 0.05). Conclusions These cross-sectional data suggest that strengthening governing boards to perform essential responsibilities may result in improved hospital performance. [ABSTRACT FROM AUTHOR]

Background: Poor mental health is a leading cause of disability worldwide with considerable negative impacts, particularly in low-income countries. Nevertheless, empirical evidence on its national prevalence in low-income countries, particularly in Africa, is limited. Additionally, researchers and policy makers are now calling for empirical investigations of the association between empowerment and poor mental health among women. We therefore sought to estimate the national prevalence of poor mental health in Ghana, explore its correlates on a national level, and examine associations between empowerment and poor mental health among women. Methods: We conducted a cross-sectional analysis using data from a nationally representative survey conducted in Ghana in 2009-2010. Interviews were conducted face-to-face with participants (N = 9,524 for overall sample; n = 3,007 for women in relationships). We used the Kessler Psychological Distress Scale (K10) to measure psychological distress and assessed women's attitudes about their roles in decision-making, attitudes towards intimate partner violence, partner control, and partner abuse. We used weighted multivariable multinomial regression models to determine the factors independently associated with experiencing psychological distress for our overall sample and for women in relationships. Results: Overall, 18.7% of the sample reported either moderate (11.7%) or severe (7.0%) psychological distress. The prevalence of psychological distress was higher among women than men. Overall, the prevalence of psychological distress differed by gender, marital status, education, wealth, region, health and religion, but not by age or urban/ rural location. Women who reported having experienced physical abuse, increased partner control, and who were more accepting of women's disempowerment had greater likelihoods of psychological distress (P-values < 0.05). Conclusions: Psychological distress is substantial among both men and women in Ghana, with nearly 20% having moderate or severe psychological distress, an estimate higher than those found among South African (16%) or Australian (11%) adults. Women who are disempowered in the context of intimate relationships may be particularly vulnerable to psychological distress. Results identify populations to be targeted by interventions aiming to improve mental health. [ABSTRACT FROM AUTHOR]

Objectives: Mental health disorders account for 13% of the global burden of disease, a burden that low-income countries are generally ill-equipped to handle. Research evaluating the association between mental health and employment in low-income countries, particularly in sub-Saharan Africa, is limited. We address this gap by examining the association between employment and psychological distress. Methods: We analyzed data from the Ghana Socioeconomic Panel Survey using logistic regression (N = 5,391 adults). In multivariable analysis, we estimated the association between employment status and psychological distress, adjusted for covariates. We calculated lost productivity from unemployment and from excess absence from work that respondents reported was because of their feelings of psychological distress. Findings: Approximately 21% of adults surveyed had moderate or severe psychological distress. Increased psychological distress was associated with increased odds of being unemployed. Men and women with moderate versus mild or no psychological distress had more than twice the odds of being unemployed. The association of severe versus mild or no distress with unemployment differed significantly by sex (P-value for interaction 0.004). Among men, the adjusted OR was 12.4 (95% CI: 7.2, 21.3), whereas the association was much smaller for women (adjusted OR = 3.8, 95% CI: 2.5, 6.0). Extrapolating these figures to the country, the lost productivity associated with moderate or severe distress translates to approximately 7% of the gross domestic product of Ghana. Conclusions: Psychological distress is strongly associated with unemployment in Ghana. The findings underscore the importance of addressing mental health issues, particularly in low-income countries. [ABSTRACT FROM AUTHOR]

Background: Use of depot medroxyprogesterone acetate (DMPA), often known by the brand name Depo-Provera, has increased globally, particularly in multiple low- and middle-income countries (LMICs). As a reproductive health technology that has scaled up in diverse contexts, DMPA is an exemplar product innovation with which to illustrate the utility of the AIDED model for scaling up family health innovations. Methods: We conducted a systematic review of the enabling factors and barriers to scaling up DMPA use in LMICs. We searched 11 electronic databases for academic literature published through January 2013 (n = 284 articles), and grey literature from major health organizations. We applied exclusion criteria to identify relevant articles from peerreviewed (n = 10) and grey literature (n = 9), extracting data on scale up of DMPA in 13 countries. We then mapped the resulting factors to the five AIDED model components: ASSESS, INNOVATE, DEVELOP, ENGAGE, and DEVOLVE. Results: The final sample of sources included studies representing variation in geographies and methodologies. We identified 15 enabling factors and 10 barriers to dissemination, diffusion, scale up, and/or sustainability of DMPA use. The greatest number of factors were mapped to the ASSESS, DEVELOP, and ENGAGE components. Conclusions: Findings offer early empirical support for the AIDED model, and provide insights into scale up of DMPA that may be relevant for other family planning product innovations. [ABSTRACT FROM AUTHOR]

Unlabelled: Background: The emigration of skilled nurses from the Philippines is an ongoing phenomenon that has impacted the quality and quantity of the nursing workforce, while strengthening the domestic economy through remittances. This study examines how the development of brain drain-responsive policies is driven by the effects of nurse migration and how such efforts aim to achieve mind-shifts among nurses, governing and regulatory bodies, and public and private institutions in the Philippines and worldwide.Methods: Interviews and focus group discussions were conducted to elicit exploratory perspectives on the policy response to nurse brain drain. Interviews with key informants from the nursing, labour and immigration sectors explored key themes behind the development of policies and programmes that respond to nurse migration. Focus group discussions were held with practising nurses to understand policy recipients' perspectives on nurse migration and policy.Results: Using the qualitative data, a thematic framework was created to conceptualize participants' perceptions of how nurse migration has driven the policy development process. The framework demonstrates that policymakers have recognised the complexity of the brain drain phenomenon and are crafting dynamic policies and programmes that work to shift domestic and global mindsets on nurse training, employment and recruitment.Conclusions: Development of responsive policy to Filipino nurse brain drain offers a glimpse into a domestic response to an increasingly prominent global issue. As a major source of professionals migrating abroad for employment, the Philippines has formalised efforts to manage nurse migration. Accordingly, the Philippine paradigm, summarised by the thematic framework presented in this paper, may act as an example for other countries that are experiencing similar shifts in healthcare worker employment due to migration. [ABSTRACT FROM AUTHOR]

Background: Although rates of maternal and neonatal mortality have decreased in many countries over the last two decades, they remain unacceptably high, particularly in sub-Saharan Africa. Nevertheless, we know little about the quality of facility-based maternal and newborn care in low-income countries and little about the association between quality of care and health worker training, supervision, and incentives in these settings. We therefore sought to examine the quality of facility-based maternal and newborn health care by describing the implementation of recommended practices for maternal and newborn care among health care facilities. We also aimed to determine whether increased training, supervision, and incentives for health workers were associated with implementing these recommended practices. We chose to study these aims in the Republic of Rwanda, where rates of maternal and newborn mortality are high and where substantial attention is currently focused on strengthening health workforce capacity and quality.Methods: We used data from the 2007 Rwanda Service Provision Assessment. Using observations from 455 facilities and interviews from 1357 providers, we generated descriptive statistics to describe the use of recommended practices and frequencies of provider training, supervision, and incentives in the areas of antenatal, delivery, and newborn care. We then constructed multivariable regression models to examine the associations between using recommended practices and health provider training, supervision, and incentives.Results: Use of recommended practices varied widely, and very few facilities performed all recommended practices. Furthermore, in most areas of care, less than 25% of providers reported having had any pre-service or in-service training in the last 3 years. Contrary to our hypotheses, we found no evidence that training, supervision, or incentives were consistently associated with using recommended practices.Conclusion: Our findings highlight the need to improve facility-based maternal and newborn care in Rwanda and suggest that current approaches to workforce training, supervision, and incentives may not be adequate for improving these critical practices. [ABSTRACT FROM AUTHOR]

Introduction: Capacity-building programs are vital for healthcare workforce development in low- and middle-income countries. In addition to increasing human capital, participation in such programs may lead to new professional networks and access to social capital. Although network development and social capital generation were not explicit program goals, we took advantage of a natural experiment and studied the social networks that developed in the first year of an executive-education Master of Hospital and Healthcare Administration (MHA) program in Jimma, Ethiopia.Case Description: We conducted a sociometric network analysis, which included all program participants and supporters (formally affiliated educators and mentors). We studied two networks: the Trainee Network (all 25 trainees) and the Trainee-Supporter Network (25 trainees and 38 supporters). The independent variable of interest was out-degree, the number of program-related connections reported by each respondent. We assessed social capital exchange in terms of resource exchange, both informational and functional. Contingency table analysis for relational data was used to evaluate the relationship between out-degree and informational and functional exchange.Discussion and Evaluation: Both networks demonstrated growth and inclusion of most or all network members. In the Trainee Network, those with the highest level of out-degree had the highest reports of informational exchange, chi2 (1, N = 23) = 123.61, p < 0.01. We did not find a statistically significant relationship between out-degree and functional exchange in this network, chi2(1, N = 23) = 26.11, p > 0.05. In the Trainee-Supporter Network, trainees with the highest level of out-degree had the highest reports of informational exchange, chi2 (1, N = 23) = 74.93, p < 0.05. The same pattern held for functional exchange, chi2 (1, N = 23) = 81.31, p < 0.01.Conclusions: We found substantial and productive development of social networks in the first year of a healthcare management capacity-building program. Environmental constraints, such as limited access to information and communication technologies, or challenges with transportation and logistics, may limit the ability of some participants to engage in the networks fully. This work suggests that intentional social network development may be an important opportunity for capacity-building programs as healthcare systems improve their ability to manage resources and tackle emerging problems. [ABSTRACT FROM AUTHOR]

Background: Management training is fundamental to developing human resources for health. Particularly as Liberia revives its health delivery system, facility and county health team managers are central to progress. Nevertheless, such management skills are rarely prioritized in health training, and sustained capacity building in this area is limited. We describe a health management delivery program in which a north and south institution collaborated to integrate classroom and field-based training in health management and to transfer the capacity for sustained management development in Liberia. Methods: We developed and implemented a 6-month training program in health management skills (i.e. strategic problem solving, financial management, human resource management and leadership) delivered by Yale University and Mother Patern College from Liberia, with support from the Clinton HIV/AIDS Initiative. Over three 6-month cycles, responsibility for course instruction was transferred from the north institution to the south institution. A selfadministered survey was conducted of all participants completing the course to measure changes in self-rated management skills, the degree to which the course was helpful and met its stated objectives, and faculty members' responsiveness to participant needs as the transfer process occurred. Results: Respondents (n = 93, response rate 95.9%) reported substantial improvement in self-reported management skills, and rated the helpfulness of the course and the degree to which the course met its objectives highly. Levels of improvement and course ratings were similar over the three cohorts as the course was transferred to the south institution. We suggest a framework of five elements for implementing successful management training programs that can be transferred and sustained in resource-limited settings, including: 1) use a shortcourse format focusing on four key skill areas with practical tools; 2) include didactic training, on-site projects, and on-site mentoring; 3) collaborate with an in-country academic institution, willing and able to scale-up and maintain the training; 4) provide training for the in-country academic faculty; and 5) secure Ministry-level support to ensure participation. Conclusion: Our findings demonstrate key elements for scaling up and replicating educational initiatives that address management skills essential for long-term health systems strengthening in resource-poor settings. [ABSTRACT FROM AUTHOR]

Background: Despite decades of efforts to improve quality of health care, poor performance persists in many aspects of care. Less than 1% of the enormous national investment in medical research is focused on improving health care delivery. Furthermore, when effective innovations in clinical care are discovered, uptake of these innovations is often delayed and incomplete. In this paper, we build on the established principle of 'positive deviance' to propose an approach to identifying practices that improve health care quality. Methods: We synthesize existing literature on positive deviance, describe major alternative approaches, propose benefits and limitations of a positive deviance approach for research directed toward improving quality of health care, and describe an application of this approach in improving hospital care for patients with acute myocardial infarction. Results: The positive deviance approach, as adapted for use in health care, presumes that the knowledge about 'what works' is available in existing organizations that demonstrate consistently exceptional performance. Steps in this approach: identify 'positive deviants,' i.e., organizations that consistently demonstrate exceptionally high performance in the area of interest (e.g., proper medication use, timeliness of care); study the organizations in-depth using qualitative methods to generate hypotheses about practices that allow organizations to achieve top performance; test hypotheses statistically in larger, representative samples of organizations; and work in partnership with key stakeholders, including potential adopters, to disseminate the evidence about newly characterized best practices. The approach is particularly appropriate in situations where organizations can be ranked reliably based on valid performance measures, where there is substantial natural variation in performance within an industry, when openness about practices to achieve exceptional performance exists, and where there is an engaged constituency to promote uptake of discovered practices. Conclusion: The identification and examination of health care organizations that demonstrate positive deviance provides an opportunity to characterize and disseminate strategies for improving quality. [ABSTRACT FROM AUTHOR]

Background: As low- and middle-income countries experience economic development, ensuring quality of health care delivery is a central component of health reform. Nevertheless, health reforms in low- and middle-income countries have focused more on access to services rather than the quality of these services, and reporting on quality has been limited. In the present study, we sought to examine the prevalence and regional variation in key management practices in Egyptian health facilities within three domains: supervision of the facility from the Ministry of Health and Population (MOHP), managerial processes, and patient and community involvement in care.Methods: We conducted a cross-sectional analysis of data from 559 facilities surveyed with the Egyptian Service Provision Assessment (ESPA) survey in 2004, the most recent such survey in Egypt. We registered on the Measure Demographic and Health Survey (DHS) website http://legacy.measuredhs.com/login.cfm to gain access to the survey data. From the ESPA sampled 559 MOHP facilities, we excluded a total of 79 facilities because they did not offer facility-based 24-hour care or have at least one physician working in the facility, resulting in a final sample of 480 facilities. The final sample included 76 general service hospitals, 307 rural health units, and 97 maternal and child health and urban health units (MCH/urban units). We used standard frequency analyses to describe facility characteristics and tested the statistical significance of regional differences using chi-square statistics.Results: Nearly all facilities reported having external supervision within the 6 months preceding the interview. In contrast, key facility-level managerial processes, such as having routine and documented management meetings and applying quality assurance approaches, were uncommon. Involvement of communities and patients was also reported in a minority of facilities. Hospitals and health units located in Urban Egypt compared with more rural parts of Egypt were significantly more likely to have management committees that met at least monthly, to keep official records of the meetings, and to have an approach for reviewing quality assurance activities.Conclusions: Although the data precede the recent reform efforts of the MOHP, they provide a baseline against which future progress can be measured. Targeted efforts to improve facility-level management are critical to supporting quality improvement initiatives directed at improving the quality of health care throughout the country. [ABSTRACT FROM AUTHOR]

Background: Less than half of U.S. hospitals meet guidelines for prompt treatment of ST-segment elevation myocardial infarction (STEMI). The Door-to-Balloon (D2B) Alliance is a collaborative effort of more than 900 hospitals committed to implementing a set of evidence-based strategies for reducing D2B time. This study presents data on (1) the prevalence of evidence-based strategies in U.S. hospitals that participated in the D2B Alliance and (2) identifies key hospital characteristics associated with their use., Methods: We conducted a cross-sectional study of U.S. hospitals that joined the D2B Alliance through a Web-based survey about their current practices for patients with STEMI who received primary percutaneous coronary intervention (PCI). We used multivariate logistic regression to identify hospital characteristics associated with use of each strategy., Results: Of the 915 U.S. hospitals enrolled in the D2B Alliance as of June 2007, 797 (87%) completed the survey. Only 30.4% of responding hospitals reported employing at least 4 of the 5 key strategies (emergency medicine activates catheterization laboratory, single-call activation, expectation that catheterization team is available in the laboratory within 20-30 minutes after page, prompt data feedback on D2B times, use of pre-hospital electrocardiograms to activate the laboratory while the patient is en route to the hospital); 9.3% employed none of the strategies. There was no clear pattern of correlation between hospital characteristics and reported strategies., Conclusion: As of 2007, many hospitals had implemented few of the key strategies to reduce D2B time, suggesting substantial opportunity to improve care for patients with STEMI.