Transformational Change in maternity services in England: a longitudinal qualitative study of a national transformation programme ‘Early Adopter’

Background Large system transformation in health systems is designed to improve quality, outcomes and efficiency. Using empirical data from a longitudinal study of national policy-driven transformation of maternity services in England, we explore the utility of theory-based rules regarding ‘what works’ in large system transformation. Methods A longitudinal, qualitative case study was undertaken in a large diverse urban setting involving multiple hospital trusts, local authorities and other key stakeholders. Data was gathered using interviews, focus groups, non-participant observation, and a review of key documents in three phases between 2017 and 2019. The transcripts of the individual and focus group interviews were analysed thematically, using a combined inductive and deductive approach drawing on simple rules for large system transformation derived from evidence synthesis and the findings are reported in this paper. Results Alignment of transformation work with Best et al’s rules for ‘what works’ in large system transformation varied. Interactions between the rules were identified, indicating that the drivers of large system transformation are interdependent. Key challenges included the pace and scale of change that national policy required, complexity of the existing context, a lack of statutory status for the new ‘system’ limiting system leaders’ power and authority, and concurrent implementation of a new overarching system alongside multifaceted service change. Conclusions Objectives and timescales of transformation policy and plans should be realistic, flexible, responsive to feedback, and account for context. Drivers of large system transformation appear to be interdependent and synergistic. Transformation is likely to be more challenging in recently established systems where the basis of authority is not yet clearly established.

Exercise, Urban Food Production, Preparation and Consumption: Implications, Benefits and Risks to Grow-Your-Own (GYO) Gardeners

This study is the first to consider, and estimate, the influence of gardening routines on exposures to both health benefits and health risks. This holistic approach helped to contrast the healthy lifestyle of gardening with health risks from exposures to potentially toxic elements such as Cd and Pb in urban environments. A total of 120 participants who grew their own produce in an urban setting were recruited to the study. A detailed questionnaire was developed that included sections on gardening activity, cultivation and consumption of produce, consumption of commercially grown produce, and other lifestyle factors. Administered alongside the questionnaire was the Short Form 36 (v2) as a standardised tool for measuring physical and mental health. Fruit and vegetable consumption was found to be correlated with the amount of gardening individuals did in autumn/winter and was greater than fruit and vegetable consumption, on average, in the UK general population. Levels of physical activity were also found to be higher in our study than regional averages, whilst BMI was lower than average. This is the first study to find a relationship between gardening more regularly (in autumn/winter) and the physical component of the Short Form 36, and this relationship was elevated compared to non-gardening populations. The physical component scores from this study were also significantly higher for older participants, compared to means from a Western population. This finding supports studies suggesting that gardening may be more beneficial for the elderly generation. These benefits were assessed in the context of potential exposures estimated from the type and frequency of produce being consumed. The benefit of maintaining a healthy lifestyle is likely to outweigh the health risks of gardening on soils mildly contaminated with Cd and Pb but requires formal consideration within a risk management framework.

Household food insecurity is associated with child’s dietary diversity score among primary school children in two districts in Ghana

Background: Dietary diversity is generally considered as a good indicator of nutrient adequacy and is influenced by various factors at the national, household, and individual levels. Objective: The present study sought to determine the relationships between household food insecurity, primary caregivers’ nutrition knowledge, and dietary diversity of school-aged children in Ghana. Methods: This forms part of a longitudinal study conducted in the Ayawaso West Municipal district in Accra (urban setting) and the Upper Manya Krobo district (rural setting) in Ghana. Data were collected from a total of 116 caregiver-child dyads using 24-h dietary recall and a short version of the US 12-month Household Food Security Survey Module. Nutrition knowledge and sociodemographic data were obtained using a structured questionnaire. Multivariable logistic regression was used to check for factors associated with children’s dietary diversity. Results: Majority of households reported food insecurity, with a higher percentage of insecure households located in the rural area (88.9% vs. 46.5%, P ≤ 0.0001), compared to the urban setting. Diet diversity among the study children was low, with a mean (standard deviation [SD]) of 5.8 (2.1) out of 14 food groups. Children living in food insecure households were three times more likely to have received low diverse diet compared to those from food secure households (adjusted odds ratio [OR] =3.3, 95% confidence interval [CI]: 1.4–8.0). Caregivers’ nutrition knowledge was, however, not related to children’s dietary diversity. Discussion and conclusion: Household food insecurity was a main predictor of dietary diversity among school-age children in this study. Thus, caregiver knowledge in nutrition may not be enough, particularly in the presence of food insecurity to guarantee adequate nutrition for school-aged children.

SARS-CoV-2 Transmission Dynamics in Households With Children, Los Angeles, California

Objectives: Studies of household transmission of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) focused on households with children are limited. We investigated household secondary attack rate (SAR), transmission dynamics, and contributing factors in households with children.Materials and Methods: In this prospective case-ascertained study in Los Angeles County, California, all households members were enrolled if ≥1 member tested positive for SARS-CoV-2 by polymerase chain reaction (PCR). Nasopharyngeal PCRs, serology, and symptom data were obtained over multiple visits.Results: A total of 489 individuals in 105 households were enrolled from June to December 2020. The majority (77.3%) reported a household annual income of <$50,000, and most (92.9%) were of Hispanic/Latinx ethnicity. Children <18 years old accounted for 46.9% index cases, of whom 45.3% were asymptomatic. Household index cases were predominantly children during low community transmission and adults during the high community transmission period (χ2 = 7.647, p = 0.0036. The mean household SAR was 77.0% (95% CI: 69.4–84.6%). Child and adult index cases both efficiently transmitted SARS-CoV-2 within households [81.9%, (95% CI: 72.1–91.9%) vs. 72.4% (95% CI: 59.8–85.1%), p = 0.23]. Household income and pets were significantly associated with higher SAR in the multivariable analysis of household factors (p = 0.0013 and 0.004, respectively).Conclusions: The SAR in households with children in an urban setting with a large ethnic minority population is much higher than previously described. Children play important roles as index cases. SAR was disproportionately impacted by household income. Vaccination and public health efforts need special focus on children and vulnerable communities to help mitigate SARS-CoV-2 spread.

Exploring how authoritarian leadership affects commitment: the mediating roles of trust in the school principal and silence

PurposeThis study aims to explore the relationship between authoritarian leadership and commitment and the mediating roles of silence and trust in school principals.Design/methodology/approachThis study employed a cross-sectional design to illustrate the relationships among authoritarian leadership, trust in the principal, silence and affective commitment using path analysis evidence provided by 409 K–12 teachers.FindingsThe findings revealed that authoritarian leadership indirectly affected teacher commitment through trust in the principal and acquiescent silence. Furthermore, trust in the principal played a partial mediating role between authoritarian leadership and defensive silence. Authoritarian leadership behaviours decreased teachers' affective commitment by decreasing trust in the principal and increasing organisational silence.Originality/valueAlthough leadership and culture have been studied intensively in recent years, authoritarian leadership, which is more commonly seen in Eastern societies, has been less studied in school contexts in the Middle East and Asia. Thus, this study contributes to the literature by examining the factors that might influence affective commitment in schools in an urban setting: authoritarian leadership, silence and trust in school principals.

Significance of Short Story Cycle in Rachel Joyce’s A Snow Garden and Other Stories: An Analytical Study Using Complexity Theory

Rachel Joyce’s short story collection A Snow Garden and Other Stories (2015) is composed of seven stories which occur during a fortnight of the holiday, Christmas season. The collection uses narrative techniques which make it a unique set of stories. The stories have an urban setting and examine the intricacies of human relationships. The sense of interconnection highlighted by Joyce in the stories elevates it to a short story cycle. A short story cycle consists of individual stories which can stand on their own as complete narratives while also maintaining fictional links running through all the stories. The paper is an attempt to establish A Snow Garden and Other Stories as a short story cycle. It also argues that by narrating the interconnected nature of human lives Joyce’s work is exploring life as a complex system. As a scientific philosophy complexity theory explores the behavior of complex systems including human societies. Complex systems are self-organizing, dynamic, evolving networks that operate without any centralized control, similar to human societies. This paper will apply the principles of complex systems to reveal patterns of human behavior represented in Joyce’s work.

SARS-CoV-2 antibody prevalence and correlates of six ethnic groups living in Amsterdam, the Netherlands: a population-based cross-sectional study, June–October 2020

ObjectivesIt has been suggested that ethnic minorities have been disproportionally affected by the COVID-19. We aimed to determine whether prevalence and correlates of past SARS-CoV-2 exposure varied between six ethnic groups in Amsterdam, the Netherlands.Design, setting, participantsParticipants aged 25–79 years enrolled in the Healthy Life in an Urban Setting population-based prospective cohort (n=16 889) were randomly selected within ethnic groups and invited to participate in a cross-sectional COVID-19 seroprevalence substudy.Outcome measuresWe tested participants for SARS-CoV-2-specific antibodies and collected information on SARS-CoV-2 exposures. We estimated prevalence and correlates of SARS-CoV-2 exposure within ethnic groups using survey-weighted logistic regression adjusting for age, sex and calendar time.ResultsBetween 24 June and 9 October 2020, we included 2497 participants. Adjusted SARS-CoV-2 seroprevalence was comparable between ethnic Dutch (24/498; 5.1%, 95% CI 2.8% to 7.4%), South-Asian Surinamese (22/451; 4.9%, 95% CI 2.2% to 7.7%), African Surinamese (22/400; 8.3%, 95% CI 3.1% to 13.6%), Turkish (30/408; 7.9%, 95% CI 4.4% to 11.4%) and Moroccan (32/391; 7.2%, 95% CI 4.2% to 10.1%) participants, but higher among Ghanaians (95/327; 26.3%, 95% CI 18.5% to 34.0%). 57.1% of SARS-CoV-2-positive participants did not suspect or were unsure of being infected, which was lowest in African Surinamese (18.2%) and highest in Ghanaians (90.5%). Correlates of SARS-CoV-2 exposure varied across ethnic groups, while the most common correlate was having a household member suspected of infection. In Ghanaians, seropositivity was associated with older age, larger household sizes, living with small children, leaving home to work and attending religious services.ConclusionsNo remarkable differences in SARS-CoV-2 seroprevalence were observed between the largest ethnic groups in Amsterdam after the first wave of infections. The higher infection seroprevalence observed among Ghanaians, which passed mostly unnoticed, warrants wider prevention efforts and opportunities for non-symptom-based testing.

Contrasting Mineral Dust Abundances from X-Ray Diffraction and Reflectance Spectroscopy

Mineral dust particles dominate aerosol mass in the atmosphere and directly modify Earth’s radiative balance through absorption and scattering. This radiative forcing varies strongly with mineral composition, yet there is still limited knowledge on the mineralogy of atmospheric dust. In this study, we performed X-ray diffraction (XRD) and reflectance spectroscopy measurements on 37 different atmospheric dust samples collected as airfall in an urban setting to determine mineralogy and the relative proportions of minerals in the dust mixture. Most commonly, XRD has been used to characterize dust mineralogy; however, without prior special sample preparation, this technique is less effective for identifying poorly crystalline or amorphous phases. In addition to XRD measurements, we performed visible, near-infrared, and short-wave infrared (VNIR/SWIR) reflectance spectroscopy for these natural dust samples as a complementary technique to determine minerology and mineral abundances. Reflectance spectra of dust particles are a function of a nonlinear combination of mineral abundances in the mixture. Therefore, we used a Hapke radiative transfer model along with a linear spectral mixing approach to derive relative mineral abundances from reflectance spectroscopy. We compared spectrally derived abundances with those determined semi-quantitatively from XRD. Our results demonstrate that total clay mineral abundances from XRD are correlated with those from reflectance spectroscopy and follow similar trends; however, XRD underpredicts the total amount of clay for many of the samples. On the other hand, calcite abundances are significantly underpredicted by SWIR compared to XRD. This is caused by the weakening of absorption features associated with the fine particle size of the samples, as well as the presence of dark non-mineral materials (e.g., asphalt) in these samples. Another possible explanation for abundance discrepancies between XRD and SWIR is related to the differing sensitivity of the two techniques (crystal structure vs chemical bonds). Our results indicate that it is beneficial to use both XRD and reflectance spectroscopy to characterize airfall dust, because the former technique is good at identifying and quantifying the SWIR-transparent minerals (e.g., quartz, albite, and microcline), while the latter technique is superior for determining abundances for clays and non-mineral components.

Assessing the Quality of Care at Primary Health Care Level in Two Pilot Regions of Albania

The quality of care (QoC) of primary health care (PHC) services in Albania faces challenges on multiple levels including governance, access, infrastructure and health care workers. In addition, there is a lack of trust in the latter. The Health for All Project (HAP) funded by the Swiss Agency for Development and Cooperation therefore aimed at enhancing the population's health by improving PHC services and implementing health promotion activities following a multi-strategic health system strengthening approach. The objective of this article is to compare QoC before and after the 4 years of project implementation. A cross-sectional study was implemented at 38 PHC facilities in urban and rural locations in the Diber and Fier regions of Albania in 2015 and in 2018. A survey measured the infrastructure of the different facilities, provider–patient interactions through clinical observation and patient satisfaction. During clinical observations, special attention was given to diabetes and hypertensive patients. Infrastructure scores improved from base- to endline with significant changes seen on national level and for rural facilities (p < 0.01). Facility infrastructure and overall cleanliness, hygiene and basic/essential medical equipment and supplies improved at endline, while for public accountability/transparency and guidelines and materials no significant change was observed. The overall clinical observation score increased at endline overall, in both areas and in rural and urban setting. However, infection prevention and control procedures and diabetes treatment still experienced relatively low levels of performance at endline. Patient satisfaction on PHC services is generally high and higher yet at endline. The changes observed in the 38 PHC facilities in two regions in Albania between 2015 and 2018 were overall positive with improvements seen at all three levels assessed, e.g., infrastructure, service provision and patient satisfaction. However, to gain overall improvements in the QoC and move toward a more efficient and sustainable health system requires continuous investments in infrastructure alongside interventions at the provider and user level.