scholarly journals The Added Value of An Open Narrative in Verbal Autopsies – A Mixed-Methods Evaluation from Malawi

2020 ◽  
Author(s):  
Patricia Loh ◽  
Edward Fottrell ◽  
James Beard ◽  
Naor Bar-Zeev ◽  
Tambosi Phiri ◽  
...  
Keyword(s):  
Mixed Methods ◽  
Data Quality ◽  
Economic Status ◽  
Group Discussion ◽  
Health Centre ◽  
Signs And Symptoms ◽  
Added Value ◽  
World Health ◽  
Process Data ◽  
Additional Time

Abstract Background: The World Health Organization’s standardised verbal autopsy (VA) instrument consists of closed questions, ascertaining signs and symptoms of illness preceding death, and an optional open narrative. As VA analyses increasingly use automated algorithms, the inclusion of narratives should be justified. We evaluated the role of open narratives on VA processes, data quality and respondent emotion.Methods: A mixed-methods analysis was conducted using VA process data for deaths of children aged 0–59 months between April 2013 and November 2016 in Mchinji district, Malawi. Deaths were randomised at the point of interview to receive closed questions only or an open narrative followed by closed questions. Upon concluding the VA, interviewers self-completed questions relating to respondent emotions. Logistic regression was conducted to determine associations with visible emotions during VAs. A group discussion with the interviewers was conducted at the project end, to understand field experiences and explore future recommendations. Qualitative data were coded using deductive themes.Results: A total of 2509 VAs were included, with 49.8% (n = 1341) allocated to open narratives. Narratives lasted a median of 7 minutes (range: 1–113 minutes). Interviewers reported improved respondent rapport and felt narratives improved data quality, although there was no difference in the proportion of deaths with an indeterminate cause (5.3% vs. 6.1%). The majority of respondents did not display visible emotions during VA (81%). Those with a narrative had higher, but not statistically significant, odds of displaying emotion (aOR: 1.20; 95% CI: 0.98, 1.47). Factors associated with visible emotions were: infant deaths compared to neonates; deaths at a health centre or en-route to hospital versus home; and higher socio-economic status. Non-parental respondents and increased time between death and interview were associated with lower odds of emotion.Conclusion: Conducting an open narrative at the start of the VA to build rapport, something valued by the interviewers, may outweigh the additional time taken and slight increase in respondents becoming emotional. However, undue burdens associated with narratives may be further justified if the quality and utility of information from the narrative was promoted through standardised recommendations.

scholarly journals Added value of an open narrative in verbal autopsies: a mixed-methods evaluation from Malawi

2021 ◽  
Vol 5 (1) ◽  
pp. e000961
Author(s):  
Patricia Loh ◽  
Edward Fottrell ◽  
James Beard ◽  
Naor Bar-Zeev ◽  
Tambosi Phiri ◽  
...  
Keyword(s):  
Mixed Methods ◽  
Data Quality ◽  
Emotional Distress ◽  
Emotional Stress ◽  
Group Discussion ◽  
Health Centre ◽  
Signs And Symptoms ◽  
Added Value ◽  
Additional Time ◽  
Automated Algorithms

BackgroundThe WHO standardised verbal autopsy (VA) instrument includes closed questions, ascertaining signs and symptoms of illness preceding death, and an optional open narrative. As VA analyses increasingly use automated algorithms, inclusion of narratives should be justified. We evaluated the role of open narratives on VA processes, data quality and respondent’s emotional stress.MethodsA mixed-methods analysis was conducted using VA data for child deaths (0–59 months), between April 2013 and November 2016 in Mchinji district, Malawi. Deaths were prospectively randomised to receive closed questions only or open narrative followed by closed questions. On concluding the VA, interviewers self-completed questions on respondents’ emotional stress. Logistic regression was used to determine associations with visible emotional distress during VAs. A group discussion with interviewers was conducted at the project end, to understand field experiences and explore future recommendations; data were coded using deductive themes.Results2509 VAs were included, with 49.8% (n=1341) randomised to open narratives. Narratives lasted a median of 7 minuntes (range: 1–113). Interviewers described improved rapport and felt narratives improved data quality, although there was no difference in the proportion of deaths with an indeterminate cause using an automated algorithm (5.3% vs 6.1%). The majority of respondents did not display visible emotional stress (81%). Those with a narrative had higher, but not statistically significant, odds of emotional distress (adjusted OR: 1.20; 95% CI: 0.98 to 1.47). Factors associated with emotional stress were: infant deaths versus neonates; deaths at a health centre or en-route to hospital versus home; and higher socioeconomic status. Non-parental respondents and increased time between death and interview were associated with lower odds of emotional distress.ConclusionConducting an open narrative may help build rapport, something valued by the interviewers. However, additional time and emotional burdens should be further justified, with quality and utility of narratives promoted through standardised recommendations.

scholarly journals Health management information system (HMIS) data quality and associated factors in Massaguet district, Chad

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Azoukalné Moukénet ◽  
Monica Anna de Cola ◽  
Charlotte Ward ◽  
Honoré Beakgoubé ◽  
Kevin Baker ◽  
...  
Keyword(s):  
Data Quality ◽  
Associated Factors ◽  
Health Management ◽  
Health Centre ◽  
Data Accuracy ◽  
World Health ◽  
Quality Data ◽  
Health Management Information System ◽  
Management Information ◽  
Data Completeness

Abstract Background Quality data from Health Management Information Systems (HMIS) are important for tracking the effectiveness of malaria control interventions. However, HMIS data in many resource-limited settings do not currently meet standards set by the World Health Organization (WHO). We aimed to assess HMIS data quality and associated factors in Chad. Methods A cross-sectional study was conducted in 14 health facilities in Massaguet district. Data on children under 15 years were obtained from the HMIS and from the external patient register covering the period January–December 2018. An additional questionnaire was administered to 16 health centre managers to collect data on contextual variables. Patient registry data were aggregated and compared with the HMIS database at district and health centre level. Completeness and accuracy indicators were calculated as per WHO guidelines. Multivariate logistic regressions were performed on the Verification Factor for attendance, suspected and confirmed malaria cases for three age groups (1 to < 12 months, 1 to < 5 years and 5 to < 15 years) to identify associations between health centre characteristics and data accuracy. Results Health centres achieved a high level of data completeness in HMIS. Malaria data were over-reported in HMIS for children aged under 15 years. There was an association between workload and higher odds of inaccuracy in reporting of attendance among children aged 1 to < 5 years (Odds ratio [OR]: 10.57, 95% CI 2.32–48.19) and 5– < 15 years (OR: 6.64, 95% CI 1.38–32.04). Similar association was found between workload and stock-outs in register books, and inaccuracy in reporting of malaria confirmed cases. Meanwhile, we found that presence of a health technician, and of dedicated staff for data management, were associated with lower inaccuracy in reporting of clinic attendance in children aged under five years. Conclusion Data completeness was high while the accuracy was low. Factors associated with data inaccuracy included high workload and the unavailability of required data collection tools. The results suggest that improvement in working conditions for clinic personnel may improve HMIS data quality. Upgrading from paper-based forms to a web-based HMIS may provide a solution for improving data accuracy and its utility for future evaluations of health interventions. Results from this study can inform the Ministry of Health and it partners on the precautions to be taken in the use of HMIS data and inform initiatives for improving its quality.

HUBUNGAN PENDIDIKAN DAN STATUS EKONOMI DENGAN STATUS GIZI IBU HAMIL TRIMESTER III DI PUSKESMAS SOSIAL PALEMBANG TAHUN 2012

2019 ◽  
Vol 3 (1) ◽  
Author(s):  
Tirta Anggraini Tirta Anggraini
Keyword(s):  
Nutritional Status ◽  
Pregnant Women ◽  
Health Center ◽  
Economic Status ◽  
Social Health ◽  
World Health ◽  
Third Trimester ◽  
Chi Square ◽  
Cross Sectional ◽  
Health Organization

ABSTRACT According to the World Health Organization (WHO), maternal nutritional status at the time of growth and during pregnancy can affect fetal growth and development. Based on (IDHS) survey of 2007 AKI Indonesia at 228 per 100,000 live births, although this figure is still the highest in Asia. Social health center in Palembang in 2011 the number of pregnant women with good nutritional status of 67 men (97.1%). factors that influence the nutritional status of pregnant women is the temperature of the environment, economic status, habits and views of women to food, age, education, and health status. The purpose of this study is a known relationship education and economic status with nutritional status of pregnant women in the third trimester of Social Health Center Palembang in 2012. This study uses analytic survey with cross sectional approach. The population in this study were all third trimester pregnant women who visit the health center Social Palembang in May 2012, with a sample of 30 respondents. Sampling in this study with non-random methods with techniques Accidental Sampling. Data analysis carried out univariate and bivariate statistics with Chi-Square test with significance level α = 0.05. The results showed than 30 respondents there (73.3%) of respondents that good nutritional status, higher education (76.7%), and high economic status (70.0%). The results of this study showed no significant association education and economic status with nutritional status of pregnant women in the third trimester of Social Health Center Palembang in 2012. From the results of this study, researchers hope to improve the health care workers, especially health services in Antenatal Care services pay more attention to maternal risk of poor nutritional status.   ABSTRAK Menurut World Health Organization (WHO), status gizi ibu hamil pada waktu pertumbuhan dan selama hamil dapat mempengaruhi pertumbuhan dan perkembangan janin. Berdasarkan (SDKI) survei terakhir tahun 2007 AKI Indonesia sebesar 228 per 100.000 Kelahiran Hidup, meskipun demikian angka tersebut masih tertinggi di Asia.  Di Puskesmas Sosial Palembang tahun 2011 jumlah ibu hamil yang berstatus gizi baik sebesar 67 orang (97,1%). faktor-faktor yang mempengaruhi status gizi ibu hamil adalah suhu lingkungan, status ekonomi, kebiasaan dan pandangan wanita terhadap makanan, usia, pendidikan, dan status kesehatan. Tujuan penelitian ini adalah diketahuinya hubungan pendidikan dan status ekonomi dengan status gizi ibu hamil trimester III di Puskesmas Sosial Palembang tahun 2012. Penelitian ini menggunakan metode survey analitik dengan pendekatan cross sectional. Populasi pada penelitian ini adalah semua ibu hamil trimester III yang berkunjung di Puskesmas Sosial Palembang pada bulan Mei tahun 2012, dengan jumlah sampel 30 responden. Pengambilan sampel pada penelitian ini dengan metode non random dengan teknik Accidental Sampling. Analisa data dilakukan secara univariat dan bivariat dengan uji statistik Chi-Square dengan tingkat kemaknaan α = 0,05. Hasil penelitian menunjukkan dari 30 responden terdapat (73,3%) responden yang berstatus gizi baik, pendidikan tinggi (76,7%), dan status ekonomi tinggi (70,0%). Hasil penelitian ini menunjukkan ada hubungan yang bermakna pendidikan dan status ekonomi dengan status gizi ibu hamil trimester III di Puskesmas Sosial Palembang tahun 2012. Dari hasil penelitian ini, peneliti berharap petugas pelayanan kesehatan dapat meningkatkan pelayanan kesehatan terutama dalam pelayanan Antenatal Care lebih memperhatikan kehamilan ibu yang berisiko status gizi buruk.

scholarly journals Facility assessment and qualitative analysis of health worker perspectives on neonatal health in Malawi

2021 ◽  
Vol 14 (1) ◽  
Author(s):  
Mai-Lei Woo Kinshella ◽  
Alinane Linda Nyondo-Mipando ◽  
Queen Dube ◽  
David M. Goldfarb ◽  
Kondwani Kawaza
Keyword(s):  
Low Income ◽  
Service Providers ◽  
Health Centre ◽  
Newborn Health ◽  
World Health ◽  
Neonatal Health ◽  
Facility Assessment ◽  
Health Innovations ◽  
Care Assessment ◽  
Implementation Factors

Abstract Objectives The “Integrating a neonatal healthcare package for Malawi” (IMCHA#108030) project conducted mixed-methods to understand facility-based implementation factors for newborn health innovations in low-resourced health settings. The objective of the two datasets was to evaluate: (a) capacity of quality newborn care in three districts in southern Malawi, and (b) barriers and facilitators the scale up of bubble continuous positive airway pressure (CPAP), a newborn health innovation to support babies with respiratory distress. Data description The Integrated Maternal, Neonatal and Child Quality of Care Assessment and Improvement Tool (version April-2014) is a standardized facility assessment tool developed by the World Health Organization (WHO) that examines quality as well as quantity and availability. The facility survey is complemented by a qualitative dataset of illustrative quotes from health service providers and supervisors on bubble CPAP implementation factors. Research was conducted in one primary health centre (facility assessment only), three district-level hospitals (both) and a tertiary hospital (qualitative only) in southern Malawi. These datasets may be used by other researchers for insights into health systems of low-income countries and implementation factors for the roll-out of neonatal health innovations as well as to frame future research questions or preliminary exploratory research on similar topics.

scholarly journals Clinical Features and Mortality Associated with Severe Malaria in Adults in Southern Mauritania

2020 ◽  
Vol 6 (1) ◽  
pp. 1
Author(s):  
Boushab Mohamed Boushab ◽  
Mohamed Salem Ould Ahmedou Salem ◽  
Ali Ould Mohamed Salem Boukhary ◽  
Philippe Parola ◽  
Leonardo Basco
Keyword(s):  
Renal Failure ◽  
Respiratory Distress ◽  
Severe Malaria ◽  
Falciparum Malaria ◽  
Clinical Features ◽  
Signs And Symptoms ◽  
Plasmodium Falciparum Malaria ◽  
Severe Anaemia ◽  
World Health ◽  
Health Organization

Severe malaria in adults is not well-studied in Sahelian Africa. Clinical features and mortality associated with severe Plasmodium falciparum malaria in adult patients hospitalized in Kiffa, southern Mauritania, were analysed. Patients over 15 years old admitted for severe malaria between August 2016 and December 2019 were included in the present retrospective study. The World Health Organization (WHO) criteria were used to define severe malaria. The presenting clinical characteristics and outcome were compared. Of 4266 patients hospitalized during the study period, 573 (13.4%) had a positive rapid diagnostic test for malaria, and 99 (17.3%; mean age, 37.5 years; range 15–79 years; sex-ratio M/F, 2.1) satisfied the criteria for severe malaria. On admission, the following signs and symptoms were observed in more than one-fourth of the patients: fever (98%), impairment of consciousness (81.8%), multiple convulsions (70.7%), cardiovascular collapse (61.6%), respiratory distress (43.4%), severe anaemia ≤ 80 g/L (36.4%), haemoglobinuria (27.3%), and renal failure (25.3%). Patients were treated with parenteral quinine or artemether. Fourteen (14.1%) patients died. Multiple convulsions, respiratory distress, severe anaemia, haemoglobinuria, acute renal failure, jaundice, and abnormal bleeding occurred more frequently (p < 0.05) in deceased patients. Mortality due to severe falciparum malaria is high among adults in southern Mauritania. An adoption of the WHO-recommended first-line treatment for severe malaria, such as parenteral artesunate, is required to lower the mortality rate associated with severe malaria.

scholarly journals Cutaneous manifestations of COVID-19 in Mexican patients: A case series and review of literature

2021 ◽  
Vol 9 ◽  
pp. 2050313X2199719
Author(s):  
Juan Carlos Palomo-Pérez ◽  
Maria Elisa Vega-Memije ◽  
David Aguilar-Blancas ◽  
Erik González-Martínez ◽  
Lucia Rangel-Gamboa
Keyword(s):  
Respiratory Symptoms ◽  
Case Series ◽  
Signs And Symptoms ◽  
Skin Lesions ◽  
World Health ◽  
Medical Community ◽  
Atypical Pneumonia ◽  
Cutaneous Lesions ◽  
Cutaneous Manifestations ◽  
Mexican Patients

China officially recognized atypical pneumonia outbreak in December 2019; on 11 March 2020, the World Health Organization declared COVID-19 as a pandemic that is produced by a new coronavirus, named SARS-CoV-2, of rapid transmissibility, which can be asymptomatic, with mild to severe respiratory symptoms, and with cardiovascular, neurological, gastrointestinal, and cutaneous complications. Considering that the pandemic prolonged more than initially expected was prognostic, it is essential for the medical community to identify the signs and symptoms of COVID-19. Thus, this work’s objectives were to present cases of cutaneous lesions observed in COVID-19 Mexican patients. We register cutaneous lesions in COVID-19 patients referred from internal medicine and otorhinolaryngology services to dermatology. We presented four interesting cases with cutaneous lesions, including exanthema morbilliform, urticaria, chilblains, ecchymosis, and facial edema, and review the available literature. The most frequent cutaneous markers are rash, chilblains, and urticaria. Skin lesions may be the first manifestation of COVID-19, accompany initial respiratory symptoms, or appear during the disease course. Symptoms associated with vascular changes (livedo reticularis and vasculitis) are considered of poor prognosis.

scholarly journals Effectiveness of an escape room for undergraduate interprofessional learning: a mixed methods single group pre-post evaluation

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Leigh Moore ◽  
Narelle Campbell
Keyword(s):  
Mixed Methods ◽  
Rural Areas ◽  
Interprofessional Education ◽  
Added Value ◽  
Individual Student ◽  
Single Group ◽  
Interprofessional Practice ◽  
Student Focus ◽  
Practice Knowledge ◽  
Work Integrated Learning

Abstract Background Interprofessional practice (IPP) has been shown to contribute to quality service provision and improved health outcomes. This knowledge has led to the integration of interprofessional education into course curricula for many health-care disciplines. Offering interprofessional education in rural areas to students undertaking work integrated learning placements is challenging particularly because of the diversity of students and placement dates combined with the student focus on the assessable placement curriculum. This research investigated and evaluated the utility of an escape room as an educational modality that facilitates learning whilst providing a supportive and motivating learning environment. Our project focused on the acquisition of interprofessional practice knowledge and experience by a health professional student cohort. Methods This study used the novel intervention of an escape room combined with an interactive teaching session to test student engagement and learning about interprofessional practice and teamwork. The research used a mixed methods single group pre-post design. Results Fifty students (78% female) from seventeen universities and seven professions participated in teams of three to six members. Most participants (66%) had not previously completed an escape room. The results showed that the intervention provided effective and engaging learning and was intrinsically appealing to students despite its non-assessable nature. Individual student reflection on their participation showed developing insight into the critical importance of clear communication and intentional team member collaboration in the provision of effective interprofessional practice. Conclusions The escape room intervention added value to the placement curriculum and proved flexible for a heterogeneous student cohort.

scholarly journals COVID-19 Impact on Medical Practice in Sub-Saharan Africa; The Need to Guard Against Medical Negligence: A Case Report in a Health Care Facility in Kumasi, Ghana

2021 ◽  
Vol 14 ◽  
pp. 2632010X2110253
Author(s):  
Paul Poku Sampene Ossei ◽  
William Gilbert Ayibor ◽  
John Taylor ◽  
Lawrence Agyemang ◽  
Kwabena Owusu Aninkora ◽  
...  
Keyword(s):  
Laboratory Tests ◽  
Respiratory Infections ◽  
Care Facility ◽  
Health Care Facility ◽  
Signs And Symptoms ◽  
Sub Saharan Africa ◽  
World Health ◽  
African Countries ◽  
Diagnostic Dilemma ◽  
Negative Results

With the novel coronavirus disease 2019 (COVID-19) still in pandemic mode, according to the World Health Organization (WHO), the African continent has experienced continued growth in the total tally. According to the Africa Centers for Disease Control and Prevention (CDC), the virus has spread to almost all 54 recognized African countries. Figures from the CDC indicate that the highly affected countries include South Africa, Egypt, Nigeria, Algeria, Morocco, and Ghana (with more than 55 000 cases and 400 deaths as of the time of writing). The WHO and the United Nations have projected the ongoing pandemic could push medical practitioners toward high rates of clinical misdiagnosis. So far, the coronavirus pandemic has been more devastating and life-threatening than the usual seasonal flu. As of the time of writing, here is presently no proven vaccine or treatment for the disease, with the vaccines still under development; hence, a timely and accurate diagnosis could prove critical. Patients can also receive supportive care earlier if they are diagnosed early. Considering the fact that the coronavirus infection mimics the signs and symptoms of normal flu and other respiratory infections, a problem now emerges, where these symptoms are treated as manifestations of the deadly virus. This has caused a diagnostic dilemma in the absence of laboratory tests with new cases adding to the pool daily. In Ghana, many patients on suspicion of flu-like symptoms are sometimes denied the care so deserved due to the stigma associated with the disease, often in cases where laboratory tests are absent. This study is a postmortem report of a client who died while on admission at a private medical facility. It was an unconfirmed case of COVID-19, and the client was left unattended to and died, having spent 8 days on the ward. His test report was not done initially, but the diagnosis was purely based on suspicion. Nasopharyngeal swabs conducted on the fifth day of admission proved negative. Results became available on the day of the client’s demise. Postmortem findings established the actual cause of death, and it was not COVID-19 related.

scholarly journals The politics of crisis management by regional and international organizations in fighting against a global pandemic: the member states at a crossroads

2021 ◽  
pp. 002085232098451
Author(s):  
Steven Van Hecke ◽  
Harald Fuhr ◽  
Wouter Wolfs
Keyword(s):  
Crisis Management ◽  
International Organizations ◽  
Governance Structure ◽  
Added Value ◽  
World Health ◽  
The European Union ◽  
Member States ◽  
Global Pandemic ◽  
Turbulent Times ◽  
Health Organization

Despite new challenges like climate change and digitalization, global and regional organizations recently went through turbulent times due to a lack of support from several of their member states. Next to this crisis of multilateralism, the COVID-19 pandemic now seems to question the added value of international organizations for addressing global governance issues more specifically. This article analyses this double challenge that several organizations are facing and compares their ways of managing the crisis by looking at their institutional and political context, their governance structure, and their behaviour during the pandemic until June 2020. More specifically, it will explain the different and fragmented responses of the World Health Organization, the European Union and the International Monetary Fund/World Bank. With the aim of understanding the old and new problems that these international organizations are trying to solve, this article argues that the level of autonomy vis-a-vis the member states is crucial for understanding the politics of crisis management. Points for practitioners As intergovernmental bodies, international organizations require authorization by their member states. Since they also need funding for their operations, different degrees of autonomy also matter for reacting to emerging challenges, such as the COVID-19 pandemic. The potential for international organizations is limited, though through proactive and bold initiatives, they can seize the opportunity of the crisis and partly overcome institutional and political constraints.

Content of antenatal care and perception about services provided by primary hospitals in Nepal: a convergent mixed methods study

2021 ◽  
Vol 33 (2) ◽  
Author(s):  
Yubraj Acharya ◽  
Nigel James ◽  
Rita Thapa ◽  
Saman Naz ◽  
Rishav Shrestha ◽  
...  
Keyword(s):  
Quality Of Care ◽  
Mixed Methods ◽  
Antenatal Care ◽  
Quality Care ◽  
National Level ◽  
Poor Quality ◽  
Public Hospitals ◽  
World Health ◽  
Outcome Variable

Abstract Background Nepal has made significant strides in maternal and neonatal mortality over the last three decades. However, poor quality of care can threaten the gains, as maternal and newborn services are particularly sensitive to quality of care. Our study aimed to understand current gaps in the process and the outcome dimensions of the quality of antenatal care (ANC), particularly at the sub-national level. We assessed these dimensions of the quality of ANC in 17 primary, public hospitals across Nepal. We also assessed the variation in the ANC process across the patients’ socio-economic gradient. Methods We used a convergent mixed methods approach, whereby we triangulated qualitative and quantitative data. In the quantitative component, we observed interactions between providers (17 hospitals from all 7 provinces) and 198 women seeking ANC and recorded the tasks the providers performed, using the Service Provision Assessments protocol available from the Demographic and Health Survey program. The main outcome variable was the number of tasks performed by the provider during an ANC consultation. The tasks ranged from identifying potential signs of danger to providing counseling. We analyzed the resulting data descriptively and assessed the relationship between the number of tasks performed and users’ characteristics. In the qualitative component, we synthesized users’ and providers’ narratives on perceptions of the overall quality of care obtained through focus group discussions and in-depth interviews. Results Out of the 59 tasks recommended by the World Health Organization, providers performed only 22 tasks (37.3%) on average. The number of tasks performed varied significantly across provinces, with users in province 3 receiving significantly higher quality care than those in other provinces. Educated women were treated better than those with no education. Users and providers agreed that the overall quality of care was inadequate, although providers mentioned that the current quality was the best they could provide given the constraints they faced. Conclusion The quality of ANC in Nepal’s primary hospitals is poor and inequitable across education and geographic gradients. While current efforts, such as the provision of 24/7 birthing centers, can mitigate gaps in service availability, additional equipment, infrastructure and human resources will be needed to improve quality. Providers also need additional training focused on treating patients from different backgrounds equally. Our study also points to the need for additional research, both to document the quality of care more objectively and to establish key determinants of quality to inform policy.

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