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Rehabilitation services are critical to improve health outcomes, particularly at community level within primary healthcare settings. As groups with an interest in the health system, rehabilitation service users' and caregivers' involvement in various aspects of health system strengthening is important for healthcare planning and evaluation. This study aimed to explore rehabilitation service users' perceptions of the rehabilitation services and their effect on their functioning in the Johannesburg Metropolitan District. A qualitative study was conducted using purposive sampling of participants attending rehabilitation at nine provincially funded clinics. Semi-structured interviews were conducted, and data were analysed using reflexive thematic analysis. The findings revealed the theme of happy with rehabilitation services and five associated categories, namely (1) service provider actions, (2) service organisation, (3) service user actions, (4) service access, and (5) service outcomes. The participants expressed overall satisfaction with their experiences of rehabilitation services, highlighting the importance of effective communication, patient-centred care, strong therapeutic relationships, and active patient engagement to achieve positive outcomes. This study provides the evidence for maintaining and extending rehabilitation at the PHC level in support of the health policy changes proposed for South Africa. [ABSTRACT FROM AUTHOR]

In Ontario, Canada, rising rates of caregiver distress have been the 'canary in the coal mine' for a health system out of balance with the needs of an ageing population. Community-based health and social care professionals are well placed to play an important role in the caregiver support process; however, a gap has remained in the understanding of if and how caregiver support strategies are operationalized or experienced by community service providers (CSPs). The goal of this study was to describe how CSPs interpreted policy and how those interpretations may enable their work in supporting unpaid caregivers. Using a qualitative constructionist design, we interviewed 24 participants and reviewed 92 publicly available documents. Braun and Clarke's method of thematic analysis was used for analysis strategy. Four overarching themes were identified: (1) community care as a priority, (2) sidewalk accountability, (3) creative care planning through partnerships, and (4) challenges to care delivery. We found that the importance of caregivers to the health system was reflected in organizational policy and strategy. There is an opportunity to improve health outcome for caregivers and the population alike through strong leadership and a clear shared vision. Our findings also suggested that social capital was a significant factor in enabling providers in their work, leveraging long-standing relationships, and accumulated local knowledge to implement highly creative care plans. [ABSTRACT FROM AUTHOR]

Cancer mortality rates have declined during the last 28 years, but that process is not equitably shared. Disparities in cancer outcomes by race, ethnicity, socioeconomic status, sexual orientation and gender identity, and geographic location persist across the cancer care continuum. Consequently, community outreach and engagement (COE) efforts within National Cancer Institute‐Designated Cancer Center (NCI‐DCC) catchment areas have intensified during the last 10 years as has the emphasis on COE and catchment areas in NCI's Cancer Center Support Grant applications. This review article attempts to provide a historic perspective of COE within NCI‐DCCs. Improving COE has long been an important initiative for the NCI, but it was not until 2012 and 2016 that NCI‐DCCs were required to define their catchment areas rigorously and to provide specific descriptions of COE interventions, respectively. NCI‐DCCs had previously lacked adequate focus on the inclusion of historically marginalized patients in cancer innovation efforts. Integrating COE efforts throughout the research and operational aspects of the cancer centers, at both the patient and community levels, will expand the footprint of COE efforts within NCI‐DCCs. Achieving this change requires sustained commitment by the centers to adjust their activities and improve access and outcomes for historically marginalized communities. [ABSTRACT FROM AUTHOR]

Background: South Korea's public health doctor system requires physicians to provide primary healthcare in medically underserved areas, such as rural regions, as an alternative to mandatory military service. Recently, concerns have arisen over the decline in the number of public health doctors available in these underserved areas. This study reviews issues related to the public health doctor system and proposes strategies for enhancing its management. Current Concepts: The annual number of public health doctors has steadily decreased by approximately 46.6%, from 1,962 in 2008 to 1,048 in 2022. According to the survey, the reasons behind this decline include the lengthy service period of 36 months compared to the 18-month military service, poor working conditions, low financial support, unreasonable manpower deployment, and uncertain social status. Discussion and Conclusion: Several recommendations can enhance the effectiveness of the public health doctor system. First, the mandatory service period of 36 months should be shortened, and a military training period of 1–2 months should be incorporated into the overall service duration. Second, ensuring appropriate working hours, including holidays, along with improved working conditions and reasonable financial support and compensation, is essential. Third, the role of public health doctors should shift from solely providing basic primary healthcare to acting as public health managers in local communities. Lastly, a long-term plan should be developed to establish various types of medical institutions in medically underserved regions. [ABSTRACT FROM AUTHOR]

Sub‐Saharan Africa carries the highest burden of HIV, with approximately 70% of all people living with HIV (PLWH) globally living in this region. The provision of antiretroviral treatment (ART) significantly affects already overburdened health systems, which need to accommodate large volumes of ART patients while facing a shortage of professional health workers, infrastructure challenges and medical resources. Finding alternative ways to provide routine services to PLWH has become significantly more urgent. Multi‐month dispensing (MMD) of ART aims to improve access to treatment for PLWH, while also improving the efficiency of the health system. This study explores the experienced benefits and challenges of community‐based MMD in order to make recommendations for future implementation efforts. Twenty focus group discussions were conducted with members of community ART refill groups (CARGs) who received 3‐monthly or 6‐monthy MMD. Individual interviews were also conducted with health providers. All interviews and focus group discussions took place between April and June 2019 conducted by research nurses in English, Shona or Ndebele. Multiple benefits of community‐based MMD were reported, including decreased congestion in health facilities, improved service delivery, decline in staff burnout and increased time availability for CARG members due to less time spent at clinics, improved ART adherence and social support experienced amongst members of CARGs. Identified challenges included the possibility of being exposed to HIV‐related stigma when belonging to a CARG, and low levels of medical supplies and ART stock at clinics. Recommendations were made by CARG members and health care workers on how CARGs could be improved and sustained in the future. Results from this study show that the implementation of community‐based MMD holds multiple benefits at an individual and health facility level. Future recommendations include evaluating the feasibility of MMD among other vulnerable populations. [ABSTRACT FROM AUTHOR]

The coronavirus disease (COVID‐19) increased the demand for critical care spaces and the task for individual countries was to optimise the capacity of their health systems. Correlating governance and health system capacity to respond to global crises has subsequently garnered the pace in reviewing normalised forms of identifying health priorities. Aligning global health security and universal health security enhances the capacity and resilience of a health system. However, weak methods of governance hinder the alignment necessary for controlling infection spread and coping with the increase in demand for hospital critical care. A range of qualitative studies has explored staff experiences of providing care in hospitals amidst the COVID‐19 pandemic. Nonetheless, limited understanding of the influence of governance on health and social care staff experiences in response to the COVID‐19 pandemic exists. This case study aimed to explore the influence of health system governance on community care staff experiences of role transition in response to the COVID‐19 pandemic in England. We used criterion sampling to include community care staff initially recruited to deliver a community integrated model of dementia care at two facilities repurposed in March 2020 to optimise hospital critical care space. Six community care staff participated in the narrative correspondence inquiry. A lack of control over resources, limitations in collective action in decision making and lack of a voice underpinned staff experiences of role transition in contexts of current crisis preparedness, transition shock and moral dilemmas. Health system governance influenced the disposition of community care staff's role transition in response to the COVID‐19 pandemic. Staff's mere coping clouds the glass of wider issues in health system governance and capacity. The normative dominance that the control over resources and centrally determined health system priorities ordain require reviewing to enable optimal health and social care cross systems' capacity and resilience. [ABSTRACT FROM AUTHOR]

Purpose: How care delivery influences urban‐rural disparities in cancer outcomes is unclear. We sought to understand community oncologists' practice settings to inform cancer care delivery interventions. Methods: We conducted secondary analysis of a national dataset of providers billing Medicare from June 1, 2019 to May 31, 2020 in 13 states in the central United States. We used Kruskal‐Wallis rank and Fisher's exact tests to compare physician characteristics and practice settings among rural and urban community oncologists. Findings: We identified 1,963 oncologists practicing in 1,492 community locations; 67.5% practiced in exclusively urban locations, 11.3% in exclusively rural locations, and 21.1% in both rural and urban locations. Rural‐only, urban‐only, and urban‐rural spanning oncologists practice in an average of 1.6, 2.4, and 5.1 different locations, respectively. A higher proportion of rural community sites were solo practices (11.7% vs 4.0%, P<.001) or single specialty practices (16.4% vs 9.4%, P<.001); and had less diversity in training environments (86.5% vs 67.8% with <2 medical schools represented, P<.001) than urban community sites. Rural multispecialty group sites were less likely to include other cancer specialists. Conclusions: We identified 2 potentially distinct styles of care delivery in rural communities, which may require distinct interventions: (1) innovation‐isolated rural oncologists, who are more likely to be solo providers, provide care at few locations, and practice with doctors with similar training experiences; and (2) urban‐rural spanning oncologists who provide care at a high number of locations and have potential to spread innovation, but may face high complexity and limited opportunity for care standardization. [ABSTRACT FROM AUTHOR]

Community health workers possess valuable insight into the experiences of South Africa's children and caregivers. However, their knowledge is often overlooked in efforts to understand local realities, inform interventions, and develop relevant policies. This study aimed to explore community health workers' perspectives of the first 1000 days of life, the critical period of development between conception and two years of age. Semi-structured interviews were conducted with 15 community health workers working with mothers and infants in Khayelitsha, Cape Town. A thematic analysis suggests that the community health workers view the first 1000 days as fundamental and foundational for children's development. Furthermore, the community health workers identified key needs for mothers/caregivers and infants within the first 1000 days. The findings provide contextual grounding for the importance of the first 1000 days within South African communities. [ABSTRACT FROM AUTHOR]

Chronic disease prevention continues to be inadequate, overall and in achieving health equity, in spite of the many evidence-based practices and policies (EBPPs) available to address risk behaviors such as unhealthful eating, lack of physical activity, and tobacco use. Although clinical settings are needed for EBPPs that involve medical procedures such as immunization or early detection, dissemination of EBPPs can be effective in a variety of settings such as schools and childcare centers, worksites, social service organizations, and religious organizations. More implementation research is needed to meet challenges of effective application of EBPPs in such community settings, in which primary missions, capacity, cultures, and values do not focus on health services delivery. To address health equity, consideration of social and economic contexts of people reached in these settings is essential. This review presents lessons learned from past studies to guide future implementation research and practice across diverse settings and geographies. [ABSTRACT FROM AUTHOR]

Background: Several studies within the psychiatry literature have illustrated the importance of discharge planning and execution, as well as accessibility of outpatient follow-up post-discharge. We report the results of implementing a new seamless care transition policy to expedite post-discharge follow-up in the community Addiction and Mental Health (AMH) program in the Edmonton Zone, Alberta, Canada. The policy involved a distribution mechanism for assessment by a mental health therapist (MHT) within 7 days of discharge as well as a dedicated roster of community psychiatrists to accept newly discharged patients.Objective: Our aim was to assess the feasibility of this novel policy and to assess its effect on our outcome measures of wait time to first outpatient MHT assessment and re-admission rate to hospital.Methods: Our study involved a retrospective clinical audit with total sampling design and a comparison of data 1 year before (2015/2016 fiscal year) and 1 year after (2017/2018 fiscal year) the implementation of the seamless care policy within the Edmonton Zone. Extracted data were analyzed with simple descriptive statistics and presented as percentages, mean and median.Results: Overall, with the enactment of this policy, follow-up volumes ultimately increased, while wait times for initial assessment decreased on average for patients discharged from the hospital. In the 2015/2016 fiscal year, MHT completed 128 assessments of post-discharge patients who were new to the community AMH program compared to 298 completed new assessments for the 2017/2018 fiscal year. The corresponding wait times for the new MHT assessments were 12.7 days (median of 12 days) and 7.8 days (median of 6 days), respectively. Similarly, psychiatrists completed only 59 assessments of post-discharge patients who were new to AMH compared to 133 new psychiatric assessments for the 2017/2018 fiscal year. The corresponding wait times for the new psychiatric assessments were 15.3 days (median of 14 days) and 8.8 days (median of 7 days), respectively. We correspondingly found a slight decline in readmission rates after the implementation of our model in the subsequent fiscal year.Conclusion: We envision that this policy will set a precedent with regard to streamlining post-discharge follow-up care for admitted inpatients, ultimately improving mental health outcomes for patients. [ABSTRACT FROM AUTHOR]

Objective: To evaluate access to treatment after community-based HPV testing as testing within screen-and-treat programs has the potential to lower mortality from cervical cancer in low-resource settings.Methods: A prospective cohort study was conducted in western Kenya in 2018. Women aged 25-65 years underwent HPV self-testing. HPV-positive women were referred for cryotherapy. Participant data were obtained from questionnaires during screening and treatment. The proportion successfully accessing treatment and variables associated with successful treatment was determined.Results: Of the 750 women included, 140 (18.6%) tested positive for HPV. Of them, 135 were notified of their results, of whom 77 (59.2%) sought treatment and 73 (52.1%) received cryotherapy. Women who received treatment had a shorter time from screening to result notification (median 92 days, interquartile range [IQR] 84-104) compared to those who did not (97 days, IQR 89-106; P=0.061). In adjusted analyses, women with a history of cervical cancer screening (odds ratio [OR] 11, 95% confidence interval [CI] 1.42-85.20) and those electing result notification through a home visit (OR 4, 95% CI 1.23-14.17) were significantly more likely to acquire treatment at follow-up.Conclusion: Linkage to treatment after community-based HPV screening in this population was low, highlighting the need for strategies aimed at strengthening treatment linkage in similar settings. [ABSTRACT FROM AUTHOR]

Background and Objectives: Adults experiencing homelessness with opioid use disorder (OUD) utilize buprenorphine (BUP), a first-line medication for OUD, at very low rates. Innovative and tailored approaches are needed to reduce barriers to treatment and increase utilization of BUP in this population. This study describes a pilot Mobile Community-based Access Team (M-CAT) that used mobile technology and FaceTime in addition to existing community-based case management programs to provide BUP treatment for veterans with OUD experiencing homelessness who had difficulties engaging in the regular BUP clinic.Methods: We conducted a retrospective chart review of veterans enrolled in M-CAT or the usual BUP clinic between January 2015 and December 2017 (N = 36). We abstracted demographic, medical, substance use, prescription, health care utilization, and drug use data from medical records.Results: Twelve veterans were enrolled in M-CAT and 24 were enrolled in BUP clinic. Mean retention in treatment was 19.2 months (standard deviation [SD] = 10.2) in M-CAT and 36 months (SD = 27.6) in BUP clinic. At the endpoint, 66.7% (n = 8) in M-CAT and 100% (n = 24) in BUP clinic remained on BUP.Discussion and Conclusion: M-CAT is an innovative and tailored pilot project that successfully integrated specific OUD medication treatment into existing case management programs for veterans experiencing homelessness using mobile technology and Facetime. M-CAT can potentially increase utilization of BUP for OUD among high-risk population of veterans experiencing homelessness who are otherwise not engaged in treatment.Scientific Significance: Integrating telemedicine, BUP treatment, and community-based case management to treat OUD among veterans experiencing homelessness is feasible with high treatment retention. (Am J Addict 2020;29:485-491). [ABSTRACT FROM AUTHOR]

Poor mental health is a pressing global health problem, with high prevalence among poor populations from low-income countries. Existing studies of conditional cash transfer (CCT) effects on mental health have found positive effects. However, there is a gap in the literature on population-wide effects of cash transfers on mental health and if and how these vary by the severity of mental illness. We use the Malawian Longitudinal Study of Family and Health containing 790 adult participants in the Malawi Incentive Programme, a year-long randomized controlled trial. We estimate average and distributional quantile treatment effects and we examine how these effects vary by gender, HIV status and usage of the cash transfer. We find that the cash transfer improves mental health on average by 0.1 of a standard deviation. The effect varies strongly along the mental health distribution, with a positive effect for individuals with worst mental health of about four times the size of the average effect. These improvements in mental health are associated with increases in consumption expenditures and expenditures related to economic productivity. Our results show that CCTs can improve adult mental health for the poor living in low-income countries, particularly those with the worst mental health. [ABSTRACT FROM AUTHOR]

The growing range and complexity of community care services require robust approaches to ensuring quality. This review collated studies on the use of standards in regulating community health and social care using Social Care Online, MEDLINE and CINAHL databases. Studies were appraised by two reviewers and synthesized by study themes. Sixteen studies were synthesized under three themes: standards in quality assurance and quality improvement; effectiveness of standards; and design of regulatory standards. Standards facilitate providers in self-regulation and enable regulators to support and monitor improvement. Effectiveness of standards depends on their language and interpretation, and on organizational factors. There was little evidence of scales within quality standards. There is continuing debate about self-regulation versus external regulation. Social care service regulation requires more research. Regulatory organizations should take note of wider initiatives toward evidence-based practice in the design of quality standards. [ABSTRACT FROM AUTHOR]

Objectives: Pregnancy hypertension is associated with 7.1% of maternal deaths in India. The objective of this trial was to assess whether task-sharing care might reduce adverse pregnancy outcomes related to delays in triage, transport, and treatment.Study Design: The Indian Community-Level Interventions for Pre-eclampsia (CLIP) open-label cluster randomised controlled trial (NCT01911494) recruited pregnant women in 12 clusters (initial four-cluster internal pilot) in Belagavi and Bagalkote, Karnataka. The CLIP intervention (6 clusters) consisted of community engagement, community health workers (CHW) provided mobile health (mHeath)-guided clinical assessment, initial treatment, and referral to facility either urgently (<4 h) or non-urgently (<24 h), dependent on algorithm-defined risk. Treatment effect was estimated by multi-level logistic regression modelling, adjusted for prognostically-significant baseline variables. Predefined secondary analyses included safety and evaluation of the intensity of mHealth-guided CHW-provided contacts.Main Outcome Measures: 20% reduction in composite of maternal, fetal, and newborn mortality and major morbidity.Results: All 14,783 recruited pregnancies (7839 intervention, 6944 control) were followed-up. The primary outcome did not differ between intervention and control arms (adjusted odds ratio (aOR) 0.92 [95% confidence interval 0.74, 1.15]; p = 0.47; intraclass correlation coefficient 0.013). There were no intervention-related safety concerns following administration of either methyldopa or MgSO4, and 401 facility referrals. Compared with intervention arm women without CLIP contacts, those with ≥8 contacts suffered fewer stillbirths (aOR 0.19 [0.10, 0.35]; p < 0.001), at the probable expense of survivable neonatal morbidity (aOR 1.39 [0.97, 1.99]; p = 0.072).Conclusions: As implemented, solely community-level interventions focussed on pre-eclampsia did not improve outcomes in northwest Karnataka. [ABSTRACT FROM AUTHOR]

Objectives: Pregnancy hypertension is the third leading cause of maternal mortality in Mozambique and contributes significantly to fetal and neonatal mortality. The objective of this trial was to assess whether task-sharing care might reduce adverse pregnancy outcomes related to delays in triage, transport, and treatment.Study Design: The Mozambique Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised controlled trial (NCT01911494) recruited pregnant women in 12 administrative posts (clusters) in Maputo and Gaza Provinces. The CLIP intervention (6 clusters) consisted of community engagement, community health worker-provided mobile health-guided clinical assessment, initial treatment, and referral to facility either urgently (<4hrs) or non-urgently (<24hrs), dependent on algorithm-defined risk. Treatment effect was estimated by multi-level logistic regression modelling, adjusted for prognostically-significant baseline variables. Predefined secondary analyses included safety and evaluation of the intensity of CLIP contacts.Main Outcome Measures: 20% reduction in composite of maternal, fetal, and newborn mortality and major morbidity.Results: 15,013 women (15,123 pregnancies) were recruited in intervention (N = 7930; 2·0% loss to follow-up (LTFU)) and control (N = 7190; 2·8% LTFU) clusters. The primary outcome did not differ between intervention and control clusters (adjusted odds ratio (aOR) 1·31, 95% confidence interval (CI) [0·70, 2·48]; p = 0·40). Compared with intervention arm women without CLIP contacts, those with ≥8 contacts experienced fewer primary outcomes (aOR 0·79 (95% CI 0·63, 0·99); p = 0·041), primarily due to improved maternal outcomes (aOR 0·72 (95% CI 0·53, 0·97); p = 0·033).Interpretation: As generally implemented, the CLIP intervention did not improve pregnancy outcomes; community implementation of the WHO eight contact model may be beneficial.Funding: The University of British Columbia (PRE-EMPT), a grantee of the Bill & Melinda Gates Foundation (OPP1017337). [ABSTRACT FROM AUTHOR]

The public governance of epidemic outbreaks faces great uncertainty. Successful governance is only possible with a competent early warning system, which hinges upon efficient production, sharing, and use of relevant knowledge and information. In this process, functional scientific/professional communities are critical gatekeepers. Analyzing China's failed early warning for the COVID-19 outbreak, we show that an epidemic governance system dominated by bureaucratic forces is doomed to failure. In particular, we identify the lack of autonomy of scientific/professional communities—in this case, virologists, physicians, and epidemiologists—as one of the major contributing factors to the malfunction of the early warning system. Drawing upon the idea of community governance, we argue that only by empowering scientific/professional groups to exert efficient community governance can a state modernize its early warning system and perform better in combatting epidemics. [ABSTRACT FROM AUTHOR]

Background: A community palliative care service (CPCS) identified its after-hours support as sub-optimal in avoiding acute hospitalisation and supporting patients to remain at home. It created and conducted a pilot of an extended hours palliative care service (EHPCS) using current resources. Aims: To evaluate the efficacy of an extended hours palliative care service pilot. Methods: Retrospective chart review of after-hours calls taken before the trial, usual care, was undertaken. During the trial, quantitative data was gathered of the outcome of each after-hours call, including outcomes of occasion of service, reason for and length and times of calls. Findings: The extended hours palliative care service, compared with usual care, showed an almost 50% decrease in acute hospitalisation, nearly doubled after-hours palliative care unit admission and a 17% increase in patients staying in their home. EHPCS was positively received by CPCS staff, despite cost and workforce impact. Conclusions: EHPCS can positively impact on reducing avoidable hospitalisations and facilitate palliative care patients to be in their preferred place of care. [ABSTRACT FROM AUTHOR]

Background: Dual diagnosis (DD), as the co-occurrence of a substance use disorder and a psychiatric disorder, is underestimated, under-diagnosed and often poorly treated throughout the world, although it is highly prevalent in people suffering from a mental disorder. Aims and methods: This review analyzed 48 studies from a PubMed and PsycINFO databases search, in order to verify the state of the art regarding the organization of community health services for DD treatment. Results: Four macro-themes have been identified: service organization, critical issues, assessment tools and evidence-based interventions. An effective service recognizes the complexity of DD, promotes a common staff culture, and tailors the organization to local needs. The main critical issues in its implementation include the lack of specific staff training, the poor management of resources and the need for greater personalization of care plans, with attention to psychosocial interventions. Integrated service assessment tools can be used as a benchmark measure at the program level for implementation planning and at the national level to affect policy change. The integrated treatment model for DD should also aim to improve access to care and offer treatments based on scientific evidence. It is also evident that the integration of services can improve outcomes but it is not a guarantee for it. Conclusion: There is an urgent need to improve networking between mental health and addiction services in order to deal with DD and create new integrated intervention models, paying attention to an approach to the whole person, seen in his/her absolute uniqueness. [ABSTRACT FROM AUTHOR]

Objective: Ensuring sufficient qualified and experienced managers is difficult for public sector healthcare organisations in Australia, with a limited labour market and competition with the private sector for talented staff. Although both competency-based management and talent management have received empirical support in association with individual and organisational performance, there have been few studies exploring these concepts in the public healthcare sector. This study addresses this gap by exploring the perceived differences in demonstration of core competencies between average and higher-performing managers in public sector healthcare organisations. Methods: Mixed methods were used to define and measure a set of competencies for health service managers. In addition, supervisors of managers were asked to identify the differences in competence between the average and high-performing managers reporting to them. Results: Supervisors could clearly distinguish between average and higher-performing managers and identified related competencies. Conclusions: The consistent pattern of competence among community health and hospital public sector managers demonstrated by this study could be used to develop a strategic approach to talent management for the public healthcare sector in Australia. What is known about this topic?: Although there are validated competency frameworks for health service managers, they are rarely used in practice in Australia. What does this paper add?: This paper illustrates the perceived differences in competencies between top and average health services managers using a validated framework. What are the implications for practitioners?: The public health sector could work together to provide a more effective and efficient approach to talent management for public hospitals and community health services. [ABSTRACT FROM AUTHOR]

Problem Slovenia's model of primary health care relied on reactive, episodic care and was ill-equipped to address the country's burden of disease dominated by noncommunicable diseases. Approach The government has developed a multidisciplinary, community-based, prevention-oriented service delivery model for primary health care. A compulsory family medicine residency programme was introduced in 2000, and from 2004 screening and control of chronic diseases were established in family medicine practices. Health promotion centres were established, providing group interventions to support healthy lifestyles. After 2011, registered nurses were introduced to conduct screening for chronic diseases, provide counselling and manage patients with stable noncommunicable diseases. Local setting In 1992, the government transformed Slovenia's health financing scheme to a social insurance system based on mandatory payroll taxes. The system enabled private provision of health services, although primary care was mostly provided by publicly funded community health centres. A strong gatekeeping role was introduced. Relevant changes Despite spending less on health than the European Union (EU) average, by 2013 Slovenia's life expectancy was higher than the average for EU countries. The increase was due in part to rapidly declining infant and under-five mortality and a faster decline in premature mortality due to chronic diseases. Lessons learnt Slovenia's approach was enabled by strong public health and governance structures, along with accountability mechanisms that monitored outcomes and took corrective action when necessary. New programmes were piloted, creating a strong evidence base that facilitated obtaining sustainable financing, while national roll-out was supported by regional branches of the National Institute of Public Health. [ABSTRACT FROM AUTHOR]

Background: Hospitalisation with severe lower respiratory tract infection (LRTI) in early childhood is associated with ongoing respiratory symptoms and possible later development of bronchiectasis. We aimed to reduce this intermediate respiratory morbidity with a community intervention programme at time of discharge.Methods: This randomised, controlled, single-blind trial enrolled children aged <2 years hospitalised for severe LRTI to 'intervention' or 'control'. Intervention was three monthly community clinics treating wet cough with prolonged antibiotics referring non-responders. All other health issues were addressed, and health resilience behaviours were encouraged, with referrals for housing or smoking concerns. Controls followed the usual pathway of parent-initiated healthcare access. After 24 months, all children were assessed by a paediatrician blinded to randomisation for primary outcomes of wet cough, abnormal examination (crackles or clubbing) or chest X-ray Brasfield score ≤22.Findings: 400 children (203 intervention, 197 control) were enrolled in 2011-2012; mean age 6.9 months, 230 boys, 87% Maori/Pasifika ethnicity and 83% from the most deprived quintile. Final assessment of 321/400 (80.3%) showed no differences in presence of wet cough (33.9% intervention, 36.5% controls, relative risk (RR) 0.93, 95% CI 0.69 to 1.25), abnormal examination (21.7% intervention, 23.9% controls, RR 0.92, 95% CI 0.61 to 1.38) or Brasfield score ≤22 (32.4% intervention, 37.9% control, RR 0.85, 95% CI 0.63 to 1.17). Twelve (all intervention) were diagnosed with bronchiectasis within this timeframe.Interpretation: We have identified children at high risk of ongoing respiratory disease following hospital admission with severe LRTI in whom this intervention programme did not change outcomes over 2 years.Trial Registration Number: ACTRN12610001095055. [ABSTRACT FROM AUTHOR]

Socioeconomically disadvantaged men who have sex with men (MSM) and transgender women (TGW) share a disproportionate burden of the HIV epidemic. Providing care in the community may help improve retention and treatment outcomes of these clients. Our objective was to compare HIV outcomes between a community-based model (CBM) and a hospital-based model (HBM) of HIV care. This was a retrospective cohort study of MSM and TGW with HIV treated at community clinics or at a hospital-based clinic. The primary outcome was the cumulative probability of virologic failure (HIV viral load ≥200 copies/ml). We conducted multivariable Cox proportional hazard regression to identify differences in outcome by care setting. Of 258 MSM and TGW, approximately half received care in the CBM. They were more likely to be African American (71% versus 59%), uninsured (48% versus 39%), and used illicit drugs (40% versus 25%). There was no difference in virologic failure by setting (58% CBM, 53% HBM; cumulative incidence of virologic failure: 35% CBM, 25% HBM; adjusted HR = 1.11; 95% CI: 0.88–1.39). Despite serving clients at greater risk for failure, virologic failure in our CBM was similar to a traditional HBM for MSM and TGW living with HIV. [ABSTRACT FROM AUTHOR]

Background: Despite high quality evidence supporting multiple physical and cognitive benefits of community-based exercise for people after stroke, there is little understanding on how to facilitate uptake of these research findings to real-world programs. A common barrier is a lack of standardised training for community fitness instructors, which hampers the ability to train more instructors to deliver the program as it was designed. Scaling up program delivery, while maintaining program fidelity, is complex. The objective of this research is to explore novel use of the Template for Intervention Description and Replication (TIDier) framework to evaluate and support implementation fidelity of a community exercise program.Methods: We embedded intervention fidelity evaluation into an inaugural training program for fitness instructors who were to deliver the Fitness and Mobility Exercise Program for stroke, which has established efficacy. The training program consisted of a face-to-face workshop followed by 3 worksite 'audit and feedback coaching cycles' provided over 3 iterations of the 12-week program offered over 1 year. A modified TIDIER checklist (with 2 additional criteria) was used within the training workshop to clarify the key 'active ingredients' that were required for program fidelity, and secondly as a basis for the audit and feedback process enabling the quantitative measurement of fidelity. Data were collected from audits of observed classes and from a survey provided by fitness instructors who implemented the program.Results: We demonstrated the feasibility of the TIDier checklist to capture 14 essential items for implementation evaluation of a complex exercise intervention for people with chronic health conditions over 3 iterations of the program. Based on the audit tool, program fidelity was high and improved over time. Three content areas for workplace coaching (intensity monitoring, space, and educational tips) were identified from the audit tool and were addressed.Conclusion: Training of staff to deliver exercises to high need populations utilising workshops and workplace coaching that used the TIDier framework for training, onsite audit and feedback resulted in a high level of fidelity to the program principles. A novel checklist based on the TIDier framework was useful for embedding implementation fidelity in complex community-based interventions. [ABSTRACT FROM AUTHOR]

Background: Globally, hypertension is a leading cause of cardiovascular disease and mortality, with the majority of deaths occurring in low- and middle-income countries. Because the burden of hypertension is increasing in low resource settings with restricted infrastructure, it is imperative that new models for hypertension care are realised. One such model is the Community-based Hypertension Improvement Project (ComHIP) which employs a community-based method of task-shifting for managing hypertension. This study is a qualitative analysis of the barriers and facilitators of the main components of ComHIP.Methods: We purposively selected 55 informants for semi-structured interviews or focus group discussions, which were carried out bythree trained local researchers in Krobo, Twi or English. Informants included patients enrolled in ComHIP, health care providers and Licensed Chemical Sellers trained by ComHIP, and Ghana Health Service employees. Data were analysed using a multi-step thematic analysis.Results: While results of the effectiveness of the intervention are pending, overall, patients and nurses reported positive experiences within ComHIP, and found that it helped enable them to manage their hypertension. Healthcare providers appreciated the additional training, but had some gaps in their knowledge. Ghana Health Service employees were cautiously optimistic about the programme, but expressed some worries about the sustainability of the programme. Many informants expressed concerns over the inability of community nurses and workers to dispense anti-hypertensives, due to legal restrictions.Conclusions: The WHO recommends task-sharing as a technique for managing chronic conditions such as hypertension in resource constrained settings. ComHIP presents an example of a task-sharing programme with a high level of acceptability to all participants. Going forward, we recommend greater levels of communication and dialogue to allow community-based health workers to be allowed to dispense anti-hypertensives. [ABSTRACT FROM AUTHOR]

Medical volunteerism continues to attract many doctors from high-income nations to low- or middle-income countries (LMIC). In spite of the wealth of positive experiences of these volunteers documented in the literature, there is little evidence concerning the impact and effectiveness of their activity. We documented our model of five-year experience in the delivery of hand surgery in Cambodia, attempting a qualitative approach with attempts to understand the perceptions of local and volunteer surgeons. We conducted independent qualitative interviews with five visiting and 12 Cambodian surgeons who participated in our community-based and outcome-oriented hand surgery training programme between 2013 and 2015. Data were coded and analysed using a content analysis method and then individually grouped into categories; software was used to generate frequencies and quotations of codes. Our results highlighted factors contributing to the success of the medical volunteering programme, to its success, with suggestions for sustainability, motivation and commitment to such a programme. A clearly defined strategy by the volunteer group and a commitment to time and resources by both partners were found to be effective. [ABSTRACT FROM AUTHOR]

Background: The family doctor system has developed rapidly all over the world, and in the past few years, China has actively explored family doctor-type contracted services. This study aimed to explore the related factors of Contracted Family Doctors Services (CFDS) from the perspectives of medical staff and consumers, and to provide a stronger basis for the development and promotion of CFDS.Methods: A combination of quantitative and qualitative methods were used in this study. A self-reported questionnaire was designed through a literature analysis, group discussions, expert consultations and a pre-investigation, and conducted among community health service providers in 12 community health service centres across four provinces of China. A total of 389 participants participated, and 320 valid questionnaires were obtained, with an effective response rate of 82.3%. A total of 36 consumers participated in in-depth interviews, and the effective rate was 100.0%. An exploratory factor analysis, a confirmatory factor analysis, inductive methods, and expert consultations were used to analyse the related factors of CFDS.Results: The related factors of CFDS from the perspectives of medical staff were divided into four dimensions, with the following weighting coefficients: national government factors (31.9%), community health service agency factors (24.7%), consumer-related factors (22.6%), and contracted doctor-related factors (20.8%). The related factors of CFDS from the perspectives of consumers were divided into four dimensions, with the following frequency sequence: national government factors, contract doctor-related factors, community health service agency factors, and consumers-related factors. National government factors played an important role in CFDS from the perspectives of medical staff and consumers.Conclusions: The related factors of CFDS were the same from the perspective of medical staff and consumers, but the weight of each factor was different. The development of CFDS is inseparable from the support of policies. It is suggested that the government should strengthen the publicity of CFDS, expand the coverage, introduce personalised contract programs that meet the needs of different groups, and promote the rapid development of CFDS. [ABSTRACT FROM AUTHOR]

Objective: Despite having prevented public health center (PHC) dysfunction in response to COVID‐19 during the first wave, public health nurses (PHNs) who play a central role in preventing COVID‐19 and supporting community people were unable to share practical knowledge with other PHNs immediately. This report aims to introduce the development of novel sustainable public health care systems with regard to COVID‐19 in Japan: task sharing, securing staff, and task shifting. Methods: A descriptive study. The Japan Ministry of Health, Labour, and Welfare enlisted good practices regarding resource allocation and developing full readiness for sustainable public health care systems in September 2020. Results: Public health center developed systems for office support, infection control, hospital coordination, and outsourced inventory control. To reduce the workload of PHNs, a support team of three to four office workers developed a response manual for residents and a format for telephone consultations regarding COVID‐19. Developing an infection control team and web‐based system for hospital coordination decreased the workload of PHCs in each community to prepare for the pandemic. Conclusion: Public health center should consider managing limited human resources and focus on providing specialized care for COVID‐19 patients. Task sharing, securing staff, and task shifting are crucial strategies for developing sustainable public health care systems. [ABSTRACT FROM AUTHOR]

There is a need to bring specialized medical expertise to rural and remote areas. Project ECHO offers a method to move knowledge from specialists in academic centres using videoconference, case-base learning, and best-practices knowledge sharing. Ontario has implemented ECHO since 2014 and has demonstrated favourable outcomes among primary care clinicians. [ABSTRACT FROM AUTHOR]

Background: Healthy People 2020 has made achieving health equity one of its overarching goals; another goal is increasing the number of accredited local agencies that have Community Health Improvement Plans (CHIPs). Community Health Improvement Plans are meant to serve agencies as guiding documents for multiple years. Objectives: This study investigates the prevalence with which health disparities are addressed within CHIPs and the specific health disparities targeted by these objectives. Methods: Researchers analyzed 4,094 objectives from CHIPs of 280 local Public Health Accreditation Board (PHAB)-accredited and nonaccredited public health agencies in the United States. Results: Despite the PHAB's focus on addressing health equity, not all PHAB-accredited agencies addressed health disparities (85.4% of CHIPs analyzed). However, more accredited than nonaccredited agencies (73.9%) contained at least one objective focused on health disparities. Discussion: Findings indicate that if health equity is truly a goal of national initiatives, agencies' planning documents (e.g., CHIPs) can do a better job addressing commonly ignored populations. [ABSTRACT FROM AUTHOR]

The COBATEST Network of Community-Based Voluntary Counselling and STI/HIV Testing (CBVCT) services was created to standardise monitoring and evaluation of CBVCT services across Europe. This study aims to assess the quality of data collected in the network from 2015 to 2016. A survey was completed by 34 COBATEST Network members and an evaluation was performed of data quality based on three dimensions: transcription validity, completeness and consistency. The weakest area that we identified was data management processes. Only 8.8% of services had a written procedure to address data quality errors, 29.4% had procedures in place to resolve discrepancies and 35.3% performed quality control. We found that 41.2% of services utilised the COBATEST data, 11.8% made decisions based on the COBATEST data and 61.8% analysed their data in an independent manner for internal purposes. We conclude that while services have reliable data to support planning and management of services, improvements to quality procedures would ensure data are translated into evidence. This evidence would support further expansion of CBVCT services in the EU/EEA, including the integration of CBVCT-generated data into national surveillance systems. [ABSTRACT FROM AUTHOR]

Background: Malawi has a mature integrated community case management (iCCM) programme that is led by the Ministry of Health (MOH) but that still relies on donor support. From 2013 until 2017, under the Rapid Access Expansion (RAcE) programme, the World Health Organization supported the MOH to expand and strengthen iCCM services in four districts. This paper examines Malawi's iCCM programme performance and implementation strength in RAcE districts to further strengthen the broader programme.Methods: Baseline and endline household surveys were conducted in iCCM-eligible areas of RAcE districts. Primary caregivers of recently-sick children under five were interviewed to assess changes in care-seeking and treatment over the project period. Health surveillance assistants (HSAs) were surveyed at endline to assess iCCM implementation strength.Results: Care-seeking from HSAs and treatment of fever improved over the project period. At endline, however, less than half of sick children were brought to an HSA, many caregivers reported a preference for providers other than HSAs, and perceptions of HSAs as trusted providers of high-quality, convenient care had decreased. HSA supervision and mentorship were below MOH targets. Stockouts of malaria medicines were associated with decreased care-seeking from HSAs. Thirty percent of clusters had limited or no access to iCCM (no HSA or an HSA providing iCCM services less than 2 days per week); 50% had moderate access (an HSA providing iCCM services 2 to 4 days per week; and 20% had high access (a resident HSA providing iCCM services 5 or more days per week). Moderate access to iCCM was associated with increased care-seeking from HSAs, increased treatment by HSAs, and more positive perceptions of HSAs compared to areas with limited or no access. Areas with high access to iCCM did not show further improvements above areas with moderate access.Conclusions: Availability of well-equipped and supported HSAs is critical to the provision of iCCM services. Additional qualitative research is needed to examine challenges and to inform potential solutions. Malawi's mature iCCM programme has a strong foundation but can be improved to strengthen the continuity of care from communities to facilities and to ultimately improve child health outcomes. [ABSTRACT FROM AUTHOR]

Background: Under the World Health Organization's (WHO) integrated community case management (iCCM) Rapid Access Expansion Program (RAcE), World Vision Niger and Canada supported the Niger Ministry of Public Health to implement iCCM in four health districts in Niger in 2013. Community health workers (CHWs), known as Relais Communautaire (RCom), were deployed in their communities to diagnose and treat children under five years of age presenting with diarrhea, malaria and pneumonia and refer children with severe illness to the higher-level facilities. Two of the districts in southwest Niger piloted RCom using smartphones equipped with an application to support quality case management and provide good timely clinical data. A two-arm cluster randomized trial assessed the impact of use of the mHealth application mainly on quality of care (QoC), but also on motivation, retention and supervision.Methods: A two-arm cluster randomized trial was conducted from March to October 2016 in Dosso and Doutchi districts. The intervention arm comprised 66 RCom equipped with a smartphone and 64 in the paper-based control arm. Trained expert clinicians observed each RCom assessing sick children presenting to them (264 in intervention group; 256 in control group), re-assessed each child on the same set of parameters, and made further observations regarding perceptions of motivation, retention, supervision, drug management and caregiver satisfaction. The primary outcome was a QoC score composed of diagnostic and treatment variables. Other factors were assessed by questionnaires.Results: On average, the mHealth equipped RCom showed a 3.4% higher QoC score (mean difference of 0.83 points). They were more likely to ask about the main danger signs: convulsions (69.7% vs 50.4%, P < 0.001); incapacity to drink or eat (79.2% vs 59.4%, P < 0.001); vomiting (81.4% vs 69.9%, P < 0.01); and lethargy or unconsciousness (92.4% vs 84.8%, P < 0.01). Specifically, they consistently asked one more screening question. They were also significantly better at examining for swelling feet (40.2% vs 13.3%, P < 0.01) and advising caretakers on diarrhea, drug dosage and administration, and performed (though non-significantly) better when examining cough and breathing rates, referring all conditions, getting children to take prescribed treatments immediately and having caregivers understand treatment continuation. The control group was significantly better at diagnosing fast breathing, bloody diarrhea and severe acute malnutrition; and was somewhat better (non-significant) at treating fever and malaria. With treatment in general of the three diseases, there was no significant difference between the groups. On further inspection, 83% of the intervention group had a QoC score greater than 80% (25 out of 31), whereas only 67% of the control group had comparable performance. With respect to referrals, the intervention group performed better, mostly based on their better assessment of danger signs, with more correct (85% vs 29%) and fewer missed, plus a lower proportion of incorrect referrals, with the reverse being true for the controls (P = 0.012). There were no statistically significant differences in motivation, retention and supervision between the two groups, yet intervention RCom reported double the rate of no supervision in the last three months (31.8% vs 15.6%).Conclusions: Results suggest that use of the mHealth application led to modestly improved QoC through better assessment of the sick children and better referral decisions by RCom, but not to improvement in the actual treatment of malaria, pneumonia and diarrhea. Considering mHealth's additional costs and logistics, questions around its viability remain. Further implementation could be improved by investing in RCom capacity building, building organization culture and strengthened supervision, all essential areas for improving any CHW program. In this real-world setting, in poor and remote communities in rural Niger, this study did not support the overall value of the mHealth intervention. Much was learned for any future mHealth interventions and scale-up. [ABSTRACT FROM AUTHOR]

Background: The use of mobile health (mHealth) technology to improve quality of care (QoC) has increased over the last decade; limited evidence exists to espouse mHealth as a decision support tool, especially at the community level. This study presents evaluation findings of using a mobile application for integrated community case management (iCCM) by Malawi's health surveillance assistants (HSAs) in four pilot districts to deliver lifesaving services for children.Methods: A quasi-experimental study design compared adherence to iCCM guidelines between HSAs using mobile application (n = 137) and paper-based tools (n = 113), supplemented with 47 key informant interviews on perceptions about QoC and sustainability of iCCM mobile application. The first four sick children presenting to each HSA for an initial consultation of an illness episode were observed by a Ministry of Health iCCM trainer for assessment, classification, and treatment. Results were compared using logistic regression, controlling for child-, HSA-, and district-level characteristics, with Holm-Bonferroni-adjusted significance levels for multiple comparison.Results: HSAs using the application tended to assess sick children according to iCCM guidelines more often than HSAs using paper-based tools for cough (adjusted proportion, 98% vs 91%; P < 0.01) and five physical danger signs - chest in-drawing; alertness; palmar pallor; malnourishment; oedema (80% vs 62%; P < 0.01), but not for fever (97% vs 93%; P = 0.06), diarrhoea (94% vs 87%; P = 0.03), and three danger signs - not able to eat or drink; vomits everything; has convulsions (88% vs 79%; P = 0.01). Across illnesses and danger signs, 81% of HSAs using the application correctly classified sick children, compared to 58% of HSAs using paper-based tools (P < 0.01). No differences existed for their treatment (P = 0.27). Interview respondents corroborated these findings that using iCCM mobile application ensures protocol adherence. Respondents noted barriers to its consistent and wide use including hardware problems and limited resources.Conclusion: Generally, the mobile application is a promising tool for improving adherence to the iCCM protocol for assessing sick children and classifying illness by HSAs. Limited effects on treatments and inconsistent use suggest the need for more studies on mHealth to improve QoC at community level. [ABSTRACT FROM AUTHOR]

Background: Despite strong evidence of integrated community case management (iCCM) of childhood illnesses being a proven intervention for reducing childhood morbidity and mortality, sustainability remains a challenge in most settings. Community ownership and contribution are important factors in sustainability. The purpose of this study was to document the process and scale achieved for community engagement and mobilisation to foster ownership, service uptake and sustainability of iCCM activities.Methods: A review of data collected by the RAcE project was conducted to describe the scale and achievement of leveraging community resources to support the community-oriented resource persons (CORPs). The Rapid Access Expansion (RAcE)-supported iCCM programme in Niger state (2014-2017), aimed at improving coverage of case management services for malaria, pneumonia, and diarrhoea, among children aged 2-59 months. Resources donated were documented and costed based on the market value of goods and services at the time of donation. These monetary valuations were validated at community dialogue meetings. Descriptive statistics were used to summarise quantitative variables. The mean of the number of CORPs in active service and the percentages of the mobilised resources received by CORPs were calculated.Results: The community engagement activities included 143 engagement and advocacy visits, and meetings, 300 community dialogues, reactivation of 60 ward development committees, and 3000 radio messages in support of iCCM. 79.5% of 1659 trained CORPs were still in active iCCM service at the end of the project. We estimated the costs of all support provided by the community to CORPs in cash and kind as US$ 123 062. Types of support included cash; building materials; farming support; fuel for motorcycles, and transport fares.Conclusions: The achievements of community engagement, mobilisation, and the resources leveraged, demonstrated acceptability of the project to the beneficiaries and their willingness to contribute to uninterrupted service provision by CORPs. [ABSTRACT FROM AUTHOR]

Background: Integrated community case management (iCCM) is a strategy to train community health workers (relais communautaires or RECOs in French) in low-resource settings to provide treatment for uncomplicated malaria, pneumonia, and diarrhea for children 2-59 months of age. The package of Ministry of Public Health tools for RECOs in the Democratic Republic of Congo that was being used in 2013 included seven data collection tools and job aids which were redundant and difficult to use. As part of the WHO-supported iCCM program, the International Rescue Committee developed and evaluated a simplified set of pictorial tools and curriculum adapted for low-literate RECOs.Methods: The revised training curriculum and tools were tested in a quasi-experimental study, with 74 RECOs enrolled in the control group and 78 RECOs in the intervention group. Three outcomes were assessed during the study period from Sept. 2015-July 2016: 1) quality of care, measured by direct observation and reexamination; 2) workload, measured as the time required for each assessment - including documentation; and 3) costs of rolling out each package. Logistic regression was used to calculate odds ratios for correct treatment by the intervention group compared to the control group, controlling for characteristics of the RECOs, the child, and the catchment area.Results: Children seen by the RECOs in the intervention group had nearly three times higher odds of receiving correct treatment (adjusted odds ratio aOR = 2.9, 95% confidence interval CI = 1.3-6.3, P = 0.010). On average, the time spent by the intervention group was 10.6 minutes less (95% CI = 6.6-14.7, P < 0.001), representing 6.2 hours of time saved per month for a RECO seeing 35 children. The estimated cost savings amounts to over US$ 300 000 for a four-year program supporting 1500 RECOs.Conclusion: This study demonstrates that, at scale, simplified tools and a training package adapted for low-literate RECOs could substantially improve health outcomes for under-five children while reducing implementation costs and decreasing their workload. The training curriculum and simplified tools have been adopted nationally based on the results from this study. [ABSTRACT FROM AUTHOR]

Background: Although community engagement has been promoted as a strategy for health systems strengthening, there is need for more evidence for effectiveness of this approach. We describe an operations research (OR) Study and assessment of one form of community engagement, the development and implementation of a participatory community-based health information system (PCBHIS), in slum communities in Freetown, Sierra Leone.Methods: A child survival project was implemented in 10 slum communities, which were then randomly allocated to intervention (PCBHIS) and comparison areas. In the 5 PCBHIS communities, the findings from monthly reports submitted by community health workers (CHWs) and verbal autopsy findings for deaths of children who died before reaching 5 years of age, were processed and shared at bimonthly meetings in each community. These meetings, called Community Health Data Review (CHDR) meetings, were attended by community leaders, including members of the Ward Development Committee (WDC) and Health Management Committee (HMC), by the CHW Peer Supervisors, and by representatives of the Peripheral Health Unit. Following a review of the information, attendees proposed actions to strengthen community-based health services in their community. These meetings were held over a period of 20 months from July 2015 to March 2017. At baseline and endline, knowledge, practice and coverage (KPC) surveys measured household health-related behaviors and care-seeking behaviors. The capacity of HMCs and WDCs to engage with the local health system was also measured at baseline and endline. Reports of CHW household contact and assessments of CHW quality were obtained in the endline KPC household survey, and household contacts measured in monthly submitted reports were also tabulated.Results: The self-assessment scores of WDCs' capacity to fulfil their roles improved more in the intervention than in the comparison area for all six components, but for only 1 of the 6 was the improvement statistically significant (monthly and quarterly meetings in which Peer Supervisor and/or CHW supervision was an agenda item). The scores for the HMCs improved less in the intervention area than in the comparison area for all six components, but none of these differences were statistically significant. Topics of discussion in CHDRs focused primarily on CHW functionality. All three indicators of CHW functioning (as measured by reports submitted from CHWs) improved more in the intervention area relative to the comparison area, with 2 out of 3 measures of improvement reaching statistical significance. Five of 7 household behaviors judged to be amenable to promotion by CHWs improved more in the intervention area than in the comparison area, and 2 out of the 5 were statistically significant (feeding colostrum and appropriate infant and young child feeding). Four of the 6 care-seeking behaviors judged to be amenable to promotion by CHWs improved more in the intervention area than in the comparison area, and 1 was statistically significant (treatment of diarrhea with ORS and zinc). None of the findings that favored the comparison area were statistically significant.Conclusions: This study was implemented in challenging circumstances. The OR Study intervention was delayed because of interruptions in finalizing the national CHW policy, two separate cholera epidemics, and the Ebola epidemic lasting more than 2 years. Weaknesses in the CHW intervention severely limited the extent to which the PCBHIS could be used to observe trends in mortality and morbidity. Nonetheless, the positive results achieved in the area of functionality of the CHW intervention and community structure capacity are encouraging. Results suggest there is value in further methodologically rigorous investigations into improving community-based health system functioning through a similar approach to community engagement. [ABSTRACT FROM AUTHOR]

Background: Mozambique has one of the highest under-5 mortality rates in the world. Community health workers (CHWs) are deployed to increase access to care; in Mozambique they are known as agentes polivalentes elementares (APEs). This study aimed to investigate child deaths in an area served by APEs by analysing the causes, care seeking patterns, and the influence of social capital.Methods: Caregivers of children under-5 who died in 2015 in Inhambane province, Mozambique, were interviewed using Verbal Autopsy/Social Autopsy (VA/SA) tools with a social capital module. VA data were analysed using the WHO InterVA analytical tool to determine cause of death. SA was analysed using the INDEPTH SA framework for illnesses lasting no more than three weeks. Social capital scores were calculated.Results: 117 child deaths were reported; VA/SA was conducted for 115. Eighty-five had died from an acute illness lasting no more than three weeks, which in most cases could have been treated at community level; 50.6% died from malaria, 11.8% from HIV/AIDS, and 9.4% for each of diarrhoea and acute respiratory infections. In 35.3% the caregiver only noticed that the child was sick when symptoms of very severe illness developed. One in four children were never taken outside the home before dying. Sixteen children were first taken to an APE; of these 7 had signs of very severe illness. Caregivers who waited to seek care until the illness was very severe had a lower social capital score. The mean travel time to go to the APE was 2hrs 50min, which was not different from any other provider. Most received treatment from the APE, 3 were referred. The majority went to another provider after the APE; most to a health centre.Conclusions: The leading causes of death in children under-5 can be detected, treated or referred by APEs. Major care seeking delays took place in the home, largely due to lack of early disease recognition and late decision-making. Low social capital, distance to APEs and to referral facilities likely contribute to these delays. Increasing caregiver illness awareness is urgently needed, as well as stronger referral linkages. A review of the geographical coverage and scope of work of APEs should be conducted. [ABSTRACT FROM AUTHOR]

Aims: The aim of this study is to assess the impact of establishing a specialized community personality disorder team on out of area placements, local hospital admissions and out of hours crisis contacts for service users with borderline personality disorder. Method: This is a before–after interim evaluation of a new service. We tested, through a paired t‐test, whether the intervention generated statistically significant differences over a range of measures of service usage, including out of area placements, local hospital admissions and out of hours crisis contacts. Data from 12 months after the intervention started were compared with the previous 12 months of routine care, to determine the effect on crisis contacts, days in hospital and those returning from/or sent out of area for care. Finally, we have assessed the likelihood to generate cost savings. Results: All service users in out of area placements were repatriated to live in the community locally (100%), and there was a statistically significant decrease in inpatient admissions (80%). This was counterbalanced by a smaller but statistically significant increase in out of hours community crisis contacts (30%), although these reduced over time. Conclusion: Reorganizing local care pathways can lead to less out of area placements and less hospital admissions. © 2019 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

This article examines community service provision for older adults under the context of contracting in Zhongshan City, Guangdong Province, China. Two street communities, which adopt different models of non-competitive contracting and competitive contracting, are used to show how community services are provided for older adults. Implications for the further development of community service contracting for older adults are discussed. [ABSTRACT FROM AUTHOR]

Background: The Veterans Access, Choice and Accountability Act (hereafter, Choice Program) seeks to improve access to care by enabling eligible Veterans to receive care from community providers. Veterans Affairs (VA) primary care providers (PCPs) play a key role in making referrals to community specialists, but their frontline experiences with referrals are not well understood.Objective: To understand VA PCPs' experiences referring patients to community specialists while VA works to expand and refine the implementation of the Choice Program.Design: Qualitative study using interview methods.Participants: Semi-structured telephone interviews were conducted with VA primary care providers (N = 72 out of 599 contacted) recruited nationally.Approach: Open-ended interview questions elicited PCP perceptions and experiences with referrals to community specialists via the Choice Program. Keywords were identified using automated coding features in ATLAS.ti and evaluated using conventional content analysis to inductively describe the qualitative data.Key Results: VA PCPs emphasized problems with care coordination and continuity between the VA and community specialists (e.g., "It is extremely difficult for us to obtain and continue continuity of care because there's not much communication with the community specialist"). They described difficulties with tracking the initial referral, coordinating care after receiving community specialty care, accessing community medical records, and aligning community specialists' prescriptions with the VA formulary.Conclusions: The VA Choice Program provides access to community specialists for VA patients; however, VA primary care providers face challenges tracking referrals to community specialists and in coordinating care. Strategies to improve care coordination between the VA and community providers should focus on providing PCPs with information to follow Veterans throughout the Choice referral process and follow-up. [ABSTRACT FROM AUTHOR]

Access to rural health care is an ongoing challenge for those living in America's countryside. Hospital closures, a fragmented and dislocated care delivery system, disproportionate levels of chronic illness, and poverty combine to present significant obstacles to health reform. This article highlights the major challenges in rural health care and specifies financial and delivery policy options that can strengthen rural health care. In particular, this article suggests a return to a prepaid approach within the umbrella organizational framework of what we term "rural convening entities." These entities would serve as the control of telehealth hubs for the communities they serve. [ABSTRACT FROM AUTHOR]

Objective: To examine whether the Ways of Thinking and Ways of Doing (WoTWoD) cultural respect framework improves clinically appropriate anticipatory care in general practice and the cultural respect levels of medical practice staff.Design: Mixed methods, cluster randomised controlled trial with a participatory action research approach.Setting, Participants: Fifty-six general practices in Sydney and Melbourne, 2014-2017.Intervention: WoTWoD encompasses a toolkit (ten scenarios illustrating cross-cultural behaviour in clinical practice), one half-day workshop, cultural mentor support for practices, and a local care partnership between participating Medicare locals/primary health networks and local Aboriginal Community Controlled Health Services for guiding the program and facilitating community engagement. The intervention lasted 12 months at each practice.Major Outcomes: Rates of claims for MBS item 715 (health assessment for Aboriginal and Torres Strait Islander People) and recording of chronic disease risk factors; changes in cultural quotient (CQ) scores of practice staff.Results: Complete results were available for 28 intervention (135 GPs, 807 Indigenous patients) and 25 control practices (210 GPs, 1554 Indigenous patients). 12-Month rates of MBS item 715 claims and recording of risk factors for the two groups were not statistically significantly different, nor were mean changes in CQ scores, regardless of staff category and practice attributes.Conclusion: The WoTWoD program did not increase the rate of Indigenous health checks or improve cultural respect scores in general practice. Conceptual, methodologic, and contextual factors that influence cultural mentorship, culturally respectful clinical practice, and Indigenous health care require further investigation.Trial Registration: Australia New Zealand Clinical Trials Registry ACTRN12614000797673. [ABSTRACT FROM AUTHOR]

Nowadays, many European countries delegate health and social care responsibilities from the national level to local authorities. In January 2015, the Netherlands similarly introduced a policy programme authorising municipalities to set their own social welfare policy. A specific feature of this programme is that it stimulates municipalities to implement teams wherein professionals from different disciplines are collectively responsible for a team's decision‐making. This suggests that teams ideally have (a) high levels of functional heterogeneity (professionals from different disciplines) and (b) high levels of team autonomy (collective responsibility and decision‐making). Based on the policy programme, it can be further assumed that (a) information elaboration, (b) boundary management and (c) team cohesion in teams will improve. In practice, the majority (87%) of Dutch municipalities implemented neighbourhood teams in January 2015. A common feature of these neighbourhood teams is that the various professionals are collectively responsible for all the curative and preventive healthcare, social work and voluntary social support of the citizens in a specific neighbourhood. Nevertheless, the structure and organisation of neighbourhood teams (including the level of functional heterogeneity and team autonomy) vary within and between municipalities. Given this situation, our aim was to examine to what extent functional heterogeneity and team autonomy influence information elaboration, boundary management and team cohesion in neighbourhood teams. We developed six hypotheses based on literature that were then tested on data collected (between May 2016 and January 2017) through an online survey from 1335 professionals in 170 neighbourhood teams. An SEM analysis showed a positive effect of team autonomy on information elaboration, boundary management and team cohesion. Results further showed a negative effect of functional heterogeneity on information elaboration and boundary management. The implications of these findings for practitioners and academics are discussed. [ABSTRACT FROM AUTHOR]

Dynamic violence and injury prevention interventions located within community settings raise evaluation challenges by virtue of their complex structure, focus, and aims. They try to address many risk factors simultaneously, are often overlapped in their implementation, and their implementation may be phased over time. This article proposes a statistical and analytic framework for evaluating the effectiveness of multilevel, multisystem, multi-component, community-driven, dynamic interventions. The proposed framework builds on meta regression methodology and recently proposed approaches for pooling results from multi-component intervention studies. The methodology is applied to the evaluation of the effectiveness of South African community-centered injury prevention and safety promotion interventions. The proposed framework allows for complex interventions to be disaggregated into their constituent parts in order to extract their specific effects. The potential utility of the framework is successfully illustrated using contact crime data from select police stations in Johannesburg. The proposed framework and statistical guidelines proved to be useful to study the effectiveness of complex, dynamic, community-based interventions as a whole and of their components. The framework may help researchers and policy makers to adopt and study a specific methodology for evaluating the effectiveness of complex intervention programs. [ABSTRACT FROM AUTHOR]

Introduction The aim of this study was to explore how telehealth facilitates or impedes the provision of culturally appropriate healthcare to Indigenous Australians from the perspective of staff at an Aboriginal Community Controlled Health Service (ACCHS). Methods An exploratory qualitative study was performed. Semi-structured interviews were conducted with nine ACCHS staff. Interview transcripts were analysed using thematic analysis. Results One central theme and three sub-themes were identified. The central theme of Care provided in a supportive environment describes how telehealth enabled specialist consultations to be conducted in the safe environment of an ACCHS instead of a mainstream health service. The first sub-theme described how telehealth improved affordability and convenience and brought a reduction in the stress of healthcare. The second sub-theme explained the importance of the presence of an Indigenous health worker to facilitate culturally appropriate healthcare. The third sub-theme described how telehealth supported a holistic view of health. Discussion Our findings show culturally appropriate healthcare may be enhanced by the use of telehealth because it allows care to be provided in the supportive environment of an ACCHS. It allows the community member to have the advocacy and assistance of an Indigenous health worker and reduces the burden of travel and dislocation from community and family. [ABSTRACT FROM AUTHOR]

Background: Transition care programs (TCPs) are designed to optimise functional recovery and independence in older adults post-hospitalisation. These programs are under high demand, and understanding inefficiencies in patient flow are a key step towards service improvement.Aims: To identify service improvement opportunities in an Australian community TCP service.Methods: An in-depth retrospective study of 113 community TCP clients.Results: TCP occupancy was high (94%) and client functional level improved across the program. Inefficiencies experienced included: admission delays to the program; low completion rates (61%) predominantly due to re-hospitalisation; variable response times by Allied Health services (5-20 days); and discharge delays—the latter attributed to waiting for services such as Home Care Packages through Non-Government Organisations.Discussion: This study identified several opportunities for service improvement in a community TCP service. Health practitioners should be regularly provided with up-to-date information on efficiency of TCP services. [ABSTRACT FROM AUTHOR]