Health system barriers to implementation of TB preventive strategies in South African primary care facilities

Abstract Background With economic development, aging of the population, improved insurance coverage, and the absence of a formal referral system, bypassing primary healthcare facilities appear to have become more common. Chinese patients tend to visit the secondary or tertiary healthcare facilities directly leading to overcrowding at the higher-level facilities. This study attempts to analyze the factors associated with bypassing primary care facilities among patients of age 45 years or older in China. Methods Random effects logistic models were used to examine bypassing of primary health facilities among rural-urban patients. Data from 2011 to 2015 waves of the China Health and Retirement Longitudinal Study were used. Results Two in five older patients in China bypass primary health centers (PHC) to access care from higher-tier facilities. Urban patients were nearly twice as likely as rural patients to bypass PHC. Regardless of rural-urban residence, our analysis found that a longer travel time to primary facilities compared to higher-tier facilities increases the likelihood of bypassing. Patients with higher educational attainment were more likely to bypass PHCs. In rural areas, patients who reported their health as poor or those who experienced a recent hospitalization had a higher probability of bypassing PHC. In urban areas, older adults (age 65 years or older) were more likely to bypass PHC than the younger group. Patients with chronic conditions like diabetes also had a higher probability of bypassing. Conclusions The findings indicate the importance of strengthening the PHCs in China to improve the efficiency and effectiveness of the health system. Significantly lower out-of-pocket costs at the PHC compared to costs at the higher tiers had little or no impact on increasing the likelihood of utilizing the PHCs. Improving service quality, providing comprehensive person-centered care, focusing on family health care needs, and providing critical preventive services will help increase utilization of PHCs as well as the effectiveness and efficiency of the health system.

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Implementation of mifepristone medical abortion in Canada: pilot and feasibility testing of a survey to assess facilitators and barriers

Pilot and Feasibility Studies ◽

10.1186/s40814-019-0520-8 ◽

2019 ◽

Vol 5 (1) ◽

Cited By ~ 4

Author(s):

Courtney Devane ◽

Regina M. Renner ◽

Sarah Munro ◽

Édith Guilbert ◽

Sheila Dunn ◽

...

Keyword(s):

Primary Care ◽

Health System ◽

Diffusion Of Innovations ◽

Scale Up ◽

Medical Abortion ◽

First Trimester ◽

Validated Questionnaire ◽

Barriers To Implementation ◽

Facilitators And Barriers ◽

The Impact

Abstract Background Direct primary care provision of first-trimester medical abortion could potentially address inequitable abortion access in Canada. However, when Health Canada approved the combination medication Mifegymiso® (mifepristone 200 mg/misoprostol 800 mcg) for medical abortion in July 2015, we hypothesized that the restrictions to distribution, prescribing, and dispensing would impede the uptake of this evidence-based innovation in primary care. We developed and pilot-tested a survey related to policy and practice facilitators and barriers to assess successful initiation and ongoing clinical provision of medical abortion service by physicians undertaking mifepristone training. Additionally, we explored expert, stakeholder, and physician perceptions of the impact of facilitators and barriers on abortion services throughout Canada. Methods In phase 1, we developed a survey using 2 theoretical frameworks: Greenhalgh’s conceptual model for the Diffusion of Innovations in health service organizations (which we operationalized) and Godin’s framework to assess the impact of professional development on the uptake of new practices operationalized in Légaré’s validated questionnaire. We finalized questions in phase 2 using the modified Delphi methodology. The survey was then tested by an expert panel of 25 nationally representative physician participants and 4 clinical content experts. Qualitative analysis of transcripts enriched and validated the content by identifying these potential barriers: physicians dispensing the medication, mandatory training to become a prescriber, burdens for patients, lack of remuneration for mifepristone provision, and services available in my community. To assess the usability and reliability of the online survey, in phase 3, we pilot-tested the survey for feasibility. Results We developed and tested a 61-item Mifepristone Implementation Survey suitable to study the facilitators and barriers to implementation of mifepristone first-trimester medical abortion practice by physicians in Canada. Conclusions Our team operationalized Greenhalgh’s theoretical framework for Diffusion of Innovations in health systems to explore factors influencing the implementation of first-trimester medical abortion provision. This process may be useful for those evaluating other health system innovations. Identification of facilitators and barriers to implementation of mifepristone practice in Canada and knowledge translation has the potential to inform regulatory and health system changes to support and scale up facilitators and mitigate barriers to equitable medical abortion provision.

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Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap

BMJ Global Health ◽

10.1136/bmjgh-2020-002539 ◽

2020 ◽

Vol 5 (10) ◽

pp. e002539

Author(s):

Sanam Roder-DeWan ◽

Kojo Nimako ◽

Nana A Y Twum-Danso ◽

Archana Amatya ◽

Ana Langer ◽

...

Keyword(s):

Primary Care ◽

Health System ◽

Health Systems ◽

Low Income ◽

High Income ◽

High Quality ◽

Financial Barriers ◽

Care Facilities ◽

Health System Redesign ◽

Maternal And Newborn

Large disparities in maternal and neonatal mortality exist between low- and high-income countries. Mothers and babies continue to die at high rates in many countries despite substantial increases in facility birth. One reason for this may be the current design of health systems in most low-income countries where, unlike in high-income countries, a substantial proportion of births occur in primary care facilities that cannot offer definitive care for complications. We argue that the current inequity in care for childbirth is a global double standard that limits progress on maternal and newborn survival. We propose that health systems need to be redesigned to shift all deliveries to hospitals or other advanced care facilities to bring care in line with global best practice. Health system redesign will require investing in high-quality hospitals with excellent midwifery and obstetric care, boosting quality of primary care clinics for antenatal, postnatal, and newborn care, decreasing access and financial barriers, and mobilizing populations to demand high-quality care. Redesign is a structural reform that is contingent on political leadership that envisions a health system designed to deliver high-quality, respectful care to all women giving birth. Getting redesign right will require focused investments, local design and adaptation, and robust evaluation.

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‘Building on shaky ground’—challenges to and solutions for primary care guideline implementation in four provinces in South Africa: a qualitative study

BMJ Open ◽

10.1136/bmjopen-2019-031468 ◽

2020 ◽

Vol 10 (5) ◽

pp. e031468

Author(s):

Tamara Kredo ◽

Sara Cooper ◽

Amber Louise Abrams ◽

Jocelyn Muller ◽

Bey-Marrié Schmidt ◽

...

Keyword(s):

South Africa ◽

Primary Care ◽

Health System ◽

Patient Care ◽

South African ◽

Guideline Implementation ◽

End Users ◽

Health System Strengthening ◽

Care Guidelines ◽

Health Managers

ObjectivesClinical guidelines support evidence-informed quality patient care. Our study explored perspectives of South African subnational health managers regarding barriers to and enablers for implementation for all available primary care guidelines.DesignWe used qualitative research methods, including semistructured, individual interviews and an interpretative perspective. Thematic content analysis was used to develop data categories and themes.SettingWe conducted research in four of nine South African provinces with diverse geographic, economic and health system arrangements (Eastern Cape, Western Cape, KwaZulu-Natal, Limpopo). South Africa is a middle-income country with high levels of inequality. The settings represented public sector rural and peri-urban health facilities.ParticipantsTwenty-two participants with provincial and district health management roles, that comprised implementation and/or training on primary care guidelines, were included.ResultsParticipants recommended urgent consideration of health system challenges, particularly financial constraints, impacting on access to the guidelines themselves and to medical equipment and supplies necessary to adhere to guidelines. They suggested that overcoming service delivery gaps requires strengthening of leadership, clarification of roles and enhanced accountability. Participants suggested that inadequate numbers of skilled clinical staff hampered guideline use and, ultimately, patient care. Quality assurance of training programmes for clinicians—particularly nurses—interdisciplinary training, and strengthening post-training mentorship were recommended. Furthermore, fit-for-purpose guideline implementation necessitates considering the unique settings of facilities, including local culture and geography. This requires guideline development to include guideline end users.ConclusionsGuidelines are one of the policy tools to achieve evidence-informed, cost-effective and universal healthcare. But, if not effectively implemented, they have no impact. Subnational health managers in poorly resourced settings suggested that shortcomings in the health system, along with poor consultation with end users, affect implementation. Short-term improvements are possible through increasing access to and training on guidelines. However, health system strengthening and recognition of socio-cultural–geographic diversity are prerequisites for context-appropriate evidence-informed practice.

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Suicidal Behavior in Black South Africans

Crisis ◽

10.1027//0227-5910.24.1.24 ◽

2003 ◽

Vol 24 (1) ◽

pp. 24-28 ◽

Cited By ~ 17

Author(s):

Lourens Schlebusch ◽

Naseema B.M. Vawda ◽

Brenda A. Bosch

Keyword(s):

South African ◽

Suicidal Behavior ◽

Health Care Facilities ◽

South African Society ◽

South Africans ◽

The Past ◽

The People ◽

Care Facilities ◽

Black South Africans ◽

To Come

Summary: In the past suicidal behavior among Black South Africans has been largely underresearched. Earlier studies among the other main ethnic groups in the country showed suicidal behavior in those groups to be a serious problem. This article briefly reviews some of the more recent research on suicidal behavior in Black South Africans. The results indicate an apparent increase in suicidal behavior in this group. Several explanations are offered for the change in suicidal behavior in the reported clinical populations. This includes past difficulties for all South Africans to access health care facilities in the Apartheid (legal racial separation) era, and present difficulties of post-Apartheid transformation the South African society is undergoing, as the people struggle to come to terms with the deleterious effects of the former South African racial policies, related socio-cultural, socio-economic, and other pressures.

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Primary care discussion forum for the Indian Health System

PsycEXTRA Dataset ◽

10.1037/e596962007-005 ◽

2004 ◽

Keyword(s):

Primary Care ◽

Health System ◽

Discussion Forum ◽

Indian Health

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What Drives Utilization of Primary Care Facilities in Vietnam?

10.1596/32186 ◽

2019 ◽

Author(s):

Lan TH Vu ◽

Sarah Bales ◽

Caryn Bredenkamp

Keyword(s):

Primary Care ◽

Care Facilities

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Perceived Facilitators and Barriers to Implementation of a Decision Support Tool for Adolescent Depression and Suicidality Screening: A Qualitative Study (Preprint)

10.2196/preprints.26035 ◽

2020 ◽

Author(s):

Ana Radovic ◽

Nathan Anderson ◽

Megan Hamm ◽

Brandie George-Milford ◽

Carrie Fascetti ◽

...

Keyword(s):

Mental Health ◽

Primary Care ◽

Qualitative Study ◽

Focus Groups ◽

Decision Support Tool ◽

Depression Screening ◽

Self Disclosure ◽

Support Tool ◽

Adolescent Parent ◽

Barriers To Implementation

BACKGROUND Screening Wizard (SW) is a technology-based decision support tool aimed at guiding primary care providers (PCPs) to respond to depression and suicidality screens in adolescents. Separate screens assess adolescents’ and parents’ reports on mental health symptoms, treatment preferences, and potential treatment barriers. A detailed summary is provided to PCPs, also identifying adolescent-parent discrepancies. The goal of SW is to enhance decision making to increase utilization of evidence-based treatments. OBJECTIVE We describe a multi-stakeholder qualitative study with adolescents, parents, and providers to understand potential barriers to implementation of SW. METHODS We interviewed 11 parents and 11 adolescents, and conducted 2 focus groups with 17 healthcare providers (PCPs, nurses, therapists, staff) across 2 pediatric practices. Participants described previous experiences with screening for depression and were shown a mock-up of SW and asked for feedback. Interviews and focus groups were transcribed verbatim, and codebooks inductively developed based on content. Transcripts were double-coded, and disagreements adjudicated to full agreement. Completed coding was used to produce thematic analyses of interviews and focus groups. RESULTS We identified five main themes across the interviews and focus groups: (1) parents, adolescents, and pediatric PCPs agree that depression screening should occur in pediatric primary care; (2) there is concern that accurate self-disclosure does not always occur during depression screening; (3) Screening Wizard is viewed as a tool that could facilitate depression screening, and which might encourage more honesty in screening responses; (4) parents, adolescents and providers do not want Screening Wizard to replace mental health discussions with providers; and (5) providers want to maintain autonomy in treatment decisions. CONCLUSIONS We identified that providers, parents, and adolescents all have concerns with current screening practices, mainly regarding inaccurate self-disclosure. They recognized value in SW as a computerized tool that may elicit more honest responses and identify adolescent-parent discrepancies. Surprisingly, providers did not want the SW report to include treatment recommendations, and all groups did not want the SW report to replace conversations with the PCP about depression. While SW was originally developed as a treatment decision algorithm, this qualitative study has led us to remove this component, and instead focus on aspects identified as most useful by all groups. We hope that this initial qualitative work will improve future implementation of SW.

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