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BackgroundDisease prevalence and distribution by patient characteristics data are needed to guide "representative" patient enrollment in clinical trials and assess relevance of results to patient populations. Our objective was to describe disease prevalence, and age/sex distribution of patients with common chronic conditions from a large population sample.MethodsA cross-sectional study of all members of Clalit Health Services, alive on January 1, 2020. Included were 26 chronic diseases, and 21 types of malignancies regarded as active by being diagnosed between January 1, 2018- to January 1, 2020, or by prescription of oncologic treatment medications January 1, 2018 and January 1, 2020.ResultsData from 4,627,183 individuals, 2,274,349 males and 2,352,834 females from newborn to 110 years. Obesity (19%), hypertension (13%), diabetes mellitus (9%), esophagitis-gastritis (5.5%), thyroid disease (5.3%), asthma (5.1%), ischemic heart disease (4.5%), depression (4.5%), osteoporosis (3.8%), and atopic dermatitis (3.6%) were the ten most prevalent conditions. Proportions of age groups varied between conditions (67% of hypertensives were ≥65 years old, 24% ≥80 years; 73% with ischemic heart disease were ≥65 years, 29% ≥80 years; 59% of diabetics were ≥65 years, 17% ≥80 years; 42% of atrial fibrillation patients were ≥80 years; 40% of heart failure patients were ≥80 years). Proportions of males and females for most conditions paralleled prevalence except proportions of women increased after age 80 for cardiovascular diseases, and for diabetes after age 75. The five most frequent active cancers were breast, prostate, colon/rectal, lymphoma and melanoma. The prevalence of cancers increased with age beginning in the middle-aged groups and peaking at very old ages. Women had lower prevalence of lung cancers and accounted for lower percentages of patients with lung cancers (45 vs 55%) but similar percentages for women and men were seen in the patients with colon and rectal cancer (50.4 vs. 49.6% in women) and lymphoma (50.7 vs. 49.3% in women).ConclusionsPrevalence of medical conditions and distributions differ by age and sex. This information serves as an example and resource for data needed to describe a "representative" clinical population.

BACKGROUND: Almost half of all women in the US experience intimate partner violence (IPV) in their lifetime. The US Preventive Services Task Force recommends IPV screening paired with intervention for women of reproductive age. We aim to understand clinical practices and policies that are beneficial, detrimental, or insufficient to support survivors of IPV in a safety-net healthcare system. METHODS: We sampled 45 women who were 18-64 years old, had experienced IPV within the prior year and were patients in the San Francisco Health Network. We conducted in-depth, semi-structured interviews to elicit their perspectives on disclosing IPV and obtaining support within the healthcare system. We analyzed our data using thematic analysis and grounded theory practices informed by ecological systems theory. FINDINGS: We identified four themes regarding factors that impeded or facilitated discussing and addressing IPV across interpersonal and systemic levels relating to relationship-building, respect, autonomy and resources. (1) Interpersonal barriers included insufficient attention to relationship-building, lack of respect or concern for survivor circumstances, and feeling pressured to disclose IPV or to comply with clinicians recommended interventions. (2) Interpersonal facilitators consisted of patient-centered IPV inquiry, attentive listening, strength-based counseling and transparency regarding confidentiality. (3) Systemic barriers such as visit time limitations, clinician turn-over and feared loss of autonomy from involvement of governmental systems leading to separation from children or harm to partners, negatively affected interpersonal dynamics. (4) Systemic facilitators involved provision of resources through IPV universal education, on-site access to IPV services, and community partnerships. CONCLUSIONS: Women experiencing IPV in our study reported that relationship-building, respect, autonomy, and IPV-related resources were essential components to providing support, promoting safety, and enabling healing in the healthcare setting. Successful trauma-informed transformation of healthcare systems must optimize interpersonal and systemic factors that improve survivor wellbeing while eliminating barriers.

ObjectiveThe Mexican government has pursued multiple initiatives to improve healthcare coverage and financial protection. Yet, out-of-pocket health spending and use of private sector providers in Mexico remains high. In this paper, we sought to describe the characteristics of public and private healthcare users, describe recent visit quality across provider types, and to assess whether perceiving the public healthcare sector as poor quality is associated with private health sector use.Methods and findingsWe analyzed the cross-sectional People's Voice Survey conducted from December 2022 to January 2023. We used Chi-square tests to compare contextual, individual, and need-for-care factors and ratings of most recent visits between users of public (social security and other public providers) and private sector providers (stand-alone private providers and providers adjacent to pharmacies). We used a multivariable Poisson regression model to assess associations between low ratings of public healthcare sources and the use of private care. Among the 811 respondents with a healthcare visit in the past year, 31.2% used private sources. Private healthcare users were more educated and had higher incomes than public healthcare users. Quality of most recent visit was rated more highly in private providers (70.2% rating the visit as excellent or very good for stand-alone private providers and 54.3% for pharmacy-adjacent doctors) compared to social security (41.6%) and other public providers (46.6%). Those who perceived public health institutions as low quality had a higher probability of seeking private healthcare.ConclusionUsers rated public care visits poorly relative to private care; at the population level, perceptions of poor quality care may drive private care use and hence out-of-pocket costs. Improving public healthcare quality is necessary to ensure universal health coverage.

PURPOSE: The population with serious mental illness has high risk for hospitalization or death due to unhealthy behaviors and inadequate medical care, though the level of risk varies substantially. Programs that integrate medical and psychiatric services improve outcomes but are challenging to implement and access is limited. It would be useful to know whether benefits are confined to patients with specific levels of risk. METHODS: In a population with serious mental illness and increased risk for hospitalization or death, a specialized medical home integrated services and improved treatment and outcomes. Treatment quality, chronic illness care, care experience, symptoms, and quality of life were assessed for a median of 385 days. Analyses examine whether improvements varied by baseline level of patient risk. RESULTS: Patients with greater risk were more likely to be older, more cognitively impaired, and have worse mental health. Integrated services increased appropriate screening for body mass index, lipids, and glucose, but increases did not differ significantly by level of risk. Integrated services also improved chronic illness care, care experience, mental health-related quality of life, and psychotic symptoms. There were also no significant differences by risk level. CONCLUSIONS: There were benefits from integration of primary care and psychiatric care at all levels of increased risk, including those with extremely high risk above the 95th percentile. When developing integrated care programs, patients should be considered at all levels of risk, not only those who are the healthiest.

OBJECTIVES: The COVID-19 pandemic placed health care personnel (HCP) at risk for stress, anxiety, burnout, and post-traumatic stress disorder (PTSD). To address this, hospitals developed programs to mitigate risk. The objectives of the current study were to measure the availability and use of these programs in a cohort of academic emergency departments (EDs) in the United States early in the pandemic and identify factors associated with program use. METHODS: Cross-sectional survey of ED HCP in 21 academic EDs in 15 states between June and September 2020. Site investigators provided data on the availability of 28 programs grouped into 9 categories. Individual support programs included: financial, workload mitigation, individual COVID-19 testing, emotional (e.g., mental health hotline), and instrumental (e.g., childcare) Clinical work support programs included: COVID-19 team communication (e.g., debriefing critical incident), patient-family communication facilitation, patient services (e.g., social work, ethics consultation), and system-level exposure reduction. Participants provided corresponding data on whether they used the programs. We used generalized linear mixed models clustered on site to measure the association between demographic and facility characteristics and program use. RESULTS: We received 1,541 survey responses (96% response rate) from emergency physicians or advanced practice providers, nurses, and nonclinical staff. Program availability in each of the 9 categories was high (>95% of hospitals). Program use was variable, with clinical work support programs used more frequently (28-50% of eligible HCP across categories) than individual employee support programs (6-13% of eligible HCP across categories). Fifty-seven percent of respondents reported that the COVID-19 pandemic had affected their stress and anxiety, and 12% were at elevated risk for PTSD. Program use did not significantly differ for HCP who reported symptoms of anxiety and/or stress compared to those who did not. CONCLUSIONS: Early in the pandemic, support programs were widely available to ED HCP, but program use was low. Future work will focus on identifying barriers and facilitators to use and specific programs most likely to be effective during periods of highest occupational stress.

This protocol outlines a proposed scoping review to characterize evidence on implementation and quality improvement (QI) strategies that aim to improve equitable, evidence-informed care delivery for pregnant and birthing people with substance use disorder (SUD) in acute care. Untreated SUD during pregnancy is associated with an increased risk of overdose and severe maternal morbidity. Acute care settings are one important place to deliver equitable, evidence-informed clinical care. While clinical practice guidelines for substance use treatment and care of pregnant and birthing people with SUD exist, there are gaps in implementation. Our population of interest is pregnant and birthing people with SUD in an acute care setting. We will include US-based studies that describe or evaluate implementation or QI strategies, including experimental, observational, and descriptive studies published from 2016 to 2023. The proposed scoping review will be conducted in accordance with JBI methodology for scoping reviews and registered at OSF (registration number: BC4VZ). We will search MEDLINE (PubMed), CINAHL Complete (EBSCO), Scopus (Elsevier), and APA PsychInfo (Ovid) for published studies. Conference proceedings and Perinatal Quality Collaborative websites will be searched for grey literature. Two reviewers will independently screen then extract studies that meet inclusion criteria using a data extraction tool. The completion of this scoping review will help illuminate strengths and gaps in research and practice that aim to inform substance use treatment and care in acute care settings for pregnant and birthing people with SUD.

A growing evidence base suggests that complex healthcare problems are optimally tackled through cross-disciplinary collaboration that draws upon the expertise of diverse researchers. Yet, the influences and processes underlying effective teamwork among independent researchers are not well-understood, making it difficult to fully optimize the collaborative process. To address this gap in knowledge, we used the annual NIH mHealth Training Institutes as a testbed to develop stochastic actor-oriented models that explore the communicative interactions and psychological changes of its disciplinarily and geographically diverse participants. The models help investigate social influence and social selection effects to understand whether and how social network interactions influence perceptions of team psychological safety during the institute and how they may sway communications between participants. We found a degree of social selection effects: in particular years, scholars were likely to choose to communicate with those who had more dissimilar levels of psychological safety. We found evidence of social influence, in particular, from scholars with lower psychological safety levels and from scholars with reciprocated communications, although the sizes and directions of the social influences somewhat varied across years. The current study demonstrated the utility of stochastic actor-oriented models in understanding the team science process which can inform team science initiatives. The study results can contribute to theory-building about team science which acknowledges the importance of social influence and selection.

BACKGROUND: One critical element to optimize funding decisions involves the cost and efficiency implications of implementing alternative program components and configurations. Program planners, policy makers and funders alike are in need of relevant, strategic data and analyses to help them plan and implement effective and efficient programs. Contrary to widely accepted conceptions in both policy and academic arenas, average costs per service (so-called unit costs) vary considerably across implementation settings and facilities. The objective of this work is twofold: 1) to estimate the variation of VMMC unit costs across service delivery platforms (SDP) in Sub-Saharan countries, and 2) to develop and validate a strategy to extrapolate unit costs to settings for which no data exists. METHODS: We identified high-quality VMMC cost studies through a literature review. Authors were contacted to request the facility-level datasets (primary data) underlying their results. We standardized the disparate datasets into an aggregated database which included 228 facilities in eight countries. We estimated multivariate models to assess the correlation between VMMC unit costs and scale, while simultaneously accounting for the influence of the SDP (which we defined as all possible combinations of type of facility, ownership, urbanicity, and country), on the unit cost variation. We defined SDP as any combination of such four characteristics. Finally, we extrapolated VMMC unit costs for all SDPs in 13 countries, including those not contained in our dataset. RESULTS: The average unit cost was 73 USD (IQR: 28.3, 100.7). South Africa showed the highest within-country cost variation, as well as the highest mean unit cost (135 USD). Uganda and Namibia had minimal within-country cost variation, and Uganda had the lowest mean VMMC unit cost (22 USD). Our results showed evidence consistent with economies of scale. Private ownership and Hospitals were significant determinants of higher unit costs. By identifying key cost drivers, including country- and facility-level characteristics, as well as the effects of scale we developed econometric models to estimate unit cost curves for VMMC services in a variety of clinical and geographical settings. CONCLUSION: While our study did not produce new empirical data, our results did increase by a tenfold the availability of unit costs estimates for 128 SDPs in 14 priority countries for VMMC. It is to our knowledge, the most comprehensive analysis of VMMC unit costs to date. Furthermore, we provide a proof of concept of the ability to generate predictive cost estimates for settings where empirical data does not exist.

IntroductionTo improve retention on HIV treatment in Africa, public health programs are promoting a family of innovations to service delivery-referred to as "differentiated service delivery" (DSD) models-which seek to better meet the needs of both systems and patients by reducing unnecessary encounters, expanding access, and incorporating peers and patients in patient care. Data on the relative desirability of different models to target populations, which is currently sparse, can help guide prioritization of specific models during scale-up.MethodsWe conducted a discrete choice experiment to assess patient preferences for various characteristics of treatment services. Clinically stable people living with HIV were recruited from an HIV clinic in Kisumu, Kenya. We selected seven attributes of DSD models drawn from literature review and previous qualitative work. We created a balanced and orthogonal design to identify main term effects. A total of ten choice tasks were solicited per respondent. We calculated relative utility (RU) for each attribute level, a numerical representation of the strength of patient preference. Data were analyzed using a Hierarchical Bayesian model via Sawtooth Software.ResultsOne hundred and four respondents (37.5% men, 41.1 years mean age) preferred receiving care at a health facility, compared with home-delivery or a community meeting point (RU = 69.3, -16.2, and -53.1, respectively; p << 0.05); receiving those services from clinicians and pharmacists-as opposed to lay health workers or peers (RU = 21.5, 5.9, -24.5; p < 0.05); and preferred an individual support system over a group support system (RU = 15.0 and 4.2; p < 0.05). Likewise, patients strongly preferred longer intervals between both clinical reviews (RU = 40.1 and -50.7 for 6- and 1-month spacing, respectively; p < 0.05) and between ART collections (RU = 33.6 and -49.5 for 6- and1-month spacing, respectively; p < 0.05).ConclusionAlthough health systems find community- and peer-based DSD models attractive, clinically stable patients expressed a preference for facility-based care as long as clinical visits were extended to biannual. These data suggest that multi-month scripting and fast-track models best align with patient preferences, an insight which can help prioritize use of different DSD models in the region.

BackgroundDelays in the diagnosis of tuberculosis (TB) contribute to a substantial proportion of TB-related mortality, especially among people living with HIV (PLHIV). We sought to characterize the diagnostic journey for HIV-positive and HIV-negative patients with a new TB diagnosis in Zambia, to understand drivers of delay, and characterize their preferences for service characteristics to inform improvements in TB services.MethodsWe assessed consecutive adults with newly microbiologically-confirmed TB at two public health treatment facilities in Lusaka, Zambia. We administered a survey to document critical intervals in the TB care pathway (time to initial care-seeking, diagnosis and treatment initiation), identify bottlenecks and their reasons. We quantified patient preferences for a range of characteristics of health services using a discrete choice experiment (DCE) that assessed 7 attributes (distance, wait times, hours of operation, confidentiality, sex of provider, testing incentive, TB test speed and notification method).ResultsAmong 401 patients enrolled (median age of 34 years, 68.7% male, 46.6% HIV-positive), 60.9% and 39.1% were from a first-level and tertiary hospital, respectively. The median time from symptom onset to receipt of TB treatment was 5.0 weeks (IQR: 3.6-8.0) and was longer among HIV-positive patients seeking care at a tertiary hospital than HIV-negative patients (6.4 vs. 4.9 weeks, p = 0.002). The time from symptom onset to initial presentation for evaluation accounted for the majority of time until treatment initiation (median 3.0 weeks, IQR: 1.0-5.0)-an important minority of 11.0% of patients delayed care-seeking ≥8 weeks. The DCE found that patients strongly preferred same-day TB test results (relative importance, 37.2%), facilities close to home (18.0%), and facilities with short wait times (16.9%). Patients were willing to travel to a facility up to 7.6 kilometers further away in order to access same-day TB test results. Preferences for improving current TB services did not differ according to HIV status.ConclusionsProlonged intervals from TB symptom onset to treatment initiation were common, especially among PLHIV, and were driven by delayed health-seeking. Addressing known barriers to timely diagnosis and incorporating patients' preferences into TB services, including same-day TB test results, may facilitate earlier TB care engagement in high burden settings.

BACKGROUND:mHealth technologies are proliferating globally to address quality and timeliness of health care delivery by Community Health Workers (CHWs). This study aimed to examine CHW and beneficiaries' perceptions of a new mHealth intervention (Common Application Software [CAS] for CHWs in India. The objectives of the study were to seek perspectives of CHWs and beneficiaries on the uptake of CAS, changes in CHW-beneficiary interactions since the introduction of CAS and potential barriers faced by CHWs in use of CAS. Further, important contextual factors related to CHW-beneficiary interface and dynamics that may have a bearing on CAS have been described. METHODS:A qualitative study was conducted in two states of India (Bihar and Madhya Pradesh) from March-April 2018 with CHWs (n = 32) and beneficiaries (n = 55). All interviews were conducted and recorded in Hindi, transcribed and translated into English, and coded and thematically analysed using Dedoose. FINDINGS:The mHealth intervention was acceptable to the CHWs who felt that CAS improved their status in the communities where they worked. Beneficiaries' views were a mix of positive and negative perceptions. The divergent views between CHWs and beneficiaries surrounding the use and impact of CAS highlight an underlying mistrust, socio-cultural barriers in engagement, and technological barriers in implementation. All these contextual factors can influence the perception and uptake of CAS. CONCLUSIONS:mHealth interventions targeting CHWs and beneficiaries have the potential to improve performance of CHWs, reduce barriers to information and potentially change the behaviors of beneficiaries. While technology is an enabler for CHWs to improve their service delivery, it does not necessarily help overcome social and cultural barriers that impede CHW-beneficiary interactions to bring about improvements in knowledge and health behaviors. Future interventions for CHWs including mHealth interventions should examine contextual factors along with the acceptability, accessibility, and usability by beneficiaries and community members.

BackgroundVoluntary medical male circumcision (VMMC) remains an essential component of combination HIV prevention services, particularly in priority countries in sub-Saharan Africa. As VMMC programs seek to maximize impact and efficiency, and to support World Health Organization guidance, specific uptake-enhancing strategies are critical to identify.MethodsWe systematically reviewed the literature to evaluate the impact of service delivery interventions (e.g., facility layout, service co-location, mobile outreach) on VMMC uptake among adolescent and adult men. For the main effectiveness review, we searched for publications or conference abstracts that measured VMMC uptake or uptake of HIV testing or risk reduction counselling within VMMC services. We synthesized data by coding categories and outcomes. We also reviewed studies assessing acceptability, values/preferences, costs, and feasibility.ResultsFour randomized controlled trials and five observational studies were included in the effectiveness review. Studies took place in South Africa, Tanzania, Uganda, Zambia, and Zimbabwe. They assessed a range of service delivery innovations, including community-, school-, and facility-based interventions. Overall, interventions increased VMMC uptake; some successfully improved uptake among age-specific subpopulations, but urban-rural stratification showed no clear trends. Interventions that increased adult men's uptake included mobile services (compared to static facilities), home-based testing with active referral follow-up, and facility-based HIV testing with enhanced comprehensive sexual education. Six acceptability studies suggested interventions were generally perceived to help men choose to get circumcised. Eleven cost studies suggested interventions create economies-of-scale and efficiencies. Three studies suggested such interventions were feasible, improving facility preparedness, service quality and quantity, and efficiencies.ConclusionsInnovative changes in male-centered VMMC services can improve adult men's and adolescent boys' VMMC uptake. Limited evidence on interventions that enhance access and acceptability show promising results, but evidence gaps persist due to inconsistent intervention definition and delivery, due in part to contextual relevance and limited age disaggregation.

BackgroundIn Mozambique, HIV counseling and testing (HCT) rates are low and the cascade (or continuum) of care is poor. Perhaps more importantly, low disclosure rates and low uptake of joint testing are also related to both (1) limitations on access to services and (2) the availability of trained staff. We describe the implementation and impact of a disclosure support implemented by peer educators (PE).MethodsTen PEs, previously trained in basic HIV and post-test counseling, completed additional training on providing disclosure support for newly-diagnosed persons living with HIV (PLH).ResultsOf the 6,092 persons who received HCT, 677 (11.1%) tested positive. Any newly-diagnosed PLH who was tested when PEs were present (606 / 677) was approached about participating in the disclosure program; of these, 94.2% of PLH (n = 574) agreed to participate. Of these, at follow-up (between 1 day and 3 months later, depending on client inclination and availability) 91.9% (n = 528) said that they had disclosed their HIV infection, of whom 66.9% (n = 384) were female and 24.1% (n = 144) male. In turn, 92.7% of partners (n = 508) who had received HIV-related exposure information were tested; of these, 78.7% (n = 400) were found to be HIV-positive. Of the latter, 96.3% (n = 385) were then seen by health care providers and referred for further diagnosis and treatment.ConclusionsSupporting newly-diagnosed PLH is important both for their own health and that of others. For the newly-diagnosed, there are extensive challenges related to understanding the implications of their illness; social support from clinical care teams can be vital in planning and coping. Our study has shown that such support of PLH is also crucial to disclosure, in part via improving awareness of positive health implications for (and from) family, friends and other support networks.

BackgroundThe misdiagnosis of non-malarial fever in sub-Saharan Africa has contributed to the significant burden of pediatric pneumonia and the inappropriate use of antibiotics in this region. This study aims to assess the impact of 1) portable pulse oximeters and 2) Integrated Management of Childhood Illness (IMCI) continued education training on the diagnosis and treatment of non-malarial fever amongst pediatric patients being treated by the Global AIDS Interfaith Alliance (GAIA) in rural Malawi.MethodsThis study involved a logbook review to compare treatment patterns between five GAIA mobile clinics in Mulanje, Malawi during April-June 2019. An intervention study design was employed with four study groups: 1) 2016 control, 2) 2019 control, 3) IMCI-only, and 4) IMCI and pulse oximeter. A total of 3,504 patient logbook records were included based on these inclusion criteria: age under five years, febrile, malaria-negative, and treated during the dry season. A qualitative questionnaire was distributed to the participating GAIA providers. Fisher's Exact Testing and odds ratios were calculated to compare the prescriptive practices between each study group and reported with 95% confidence intervals.ResultsThe pre- and post-exam scores for the providers who participated in the IMCI training showed an increase in content knowledge and understanding (p0.001). However, provider responses to the qualitative questionnaires indicated alternative benefits of the training including improved illness classification and increased provider confidence.ConclusionClinics that implemented both the IMCI course and pulse oximeters exhibited a significant decrease in antibiotic prescription rates, thus highlighting the potential of this tool in combatting antibiotic overconsumption in low-resource settings. Enhanced detection of hypoxia in pediatric patients was regarded by clinicians as helpful for identifying pneumonia cases. GAIA staff appreciated the IMCI continued education training, however it did not appear to significantly impact antibiotic prescription rates and/or pneumonia diagnosis.

BackgroundThe recent introduction of direct acting antivirals for the treatment of hepatitis C virus (HCV) has dramatically improved treatment options for HCV infected patients. However, in the United States (US) treatment uptake has been low and time to initiation of therapy has been long. We sought to examine provider perspectives of facilitators and barriers to HCV treatment delivery.MethodsFrom June to August 2019, we conducted in-depth, semi-structured interviews with medical staff providing HCV care as part of a university medical center in Los Angeles, CA. In order to understand the HCV treatment process, we interviewed key staff members providing care to the majority of HCV patients seeking care at the university medical center, including hepatologists and infectious disease specialists as well as key nursing and pharmacy staff. The interviews focused on workload and activities required for HCV treatment initiation for non-cirrhotic, treatment naïve patients.ResultsProviders noted that successful HCV treatment delivery was reliant on a care model involving close collaboration between a team of providers, in particular requiring a highly coordinated effort between dedicated nursing and pharmacy staff. The HCV care team overwhelmingly reported that the process of insurance authorization was the greatest obstacle delaying treatment initiation and noted that very few patient level factors served as a barrier to treatment uptake.ConclusionsIn the US, prior authorization for HCV treatment is a requirement for most public and private insurance plans. In an era with access to therapies that allow for a cure-and until revocation of prior authorization for HCV treatment is a reality-implementing strategies that can expedite authorization to accelerate treatment access are critical. Not only will this benefit patients, but it has the potential to help expand treatment to settings that are otherwise too resource strained to successfully deliver HCV care.

BACKGROUND: Integrated cardiovascular disease (CVD) and HIV (CVD-HIV) care interventions are being adopted to tackle the growing burden of noncommunicable diseases (NCDs) in low-and middle-income countries (LMICs) but there is a paucity of studies on the feasibility of these interventions in LMICs. This scoping review aims to present evidence of the feasibility of integrated CVD-HIV care in LMICs, and the alignment of feasibility reporting in LMICs with the existing implementation science methodology. METHODS: A systematic search of published articles including systematic and narrative reviews that reported on integrated CVD-HIV care was conducted, using multiple search engines including PubMed/Medline, Global Health, and Web of Science. We examined the articles for evidence of feasibility reporting. Adopting the definition of Proctor and colleagues (2011), feasibility was defined as the extent to which an intervention was plausible in a given agency or setting. Evidence from the articles was synthesized by level of integration, the chronic care continuum, and stages of intervention development. RESULTS: Twenty studies, reported in 18 articles and 3 conferences abstracts, reported on feasibility of integrated CVD-HIV care interventions. These studies were conducted in Sub-Saharan Africa, Southeast Asia and South America. Four of these studies were conducted as feasibility studies. Eighty percent of the studies reported feasibility, using descriptive sentences that included words synonymous with feasibility terminologies in existing definition recommended by Proctor and colleagues. There was also an overlap in the use of descriptive phrases for feasibility amongst the selected studies. CONCLUSIONS: Integrating CVD and HIV care is feasible in LMICs, although methodology for reporting feasibility is inconsistent. Assessing feasibility based on settings and integration goals will provide a unique perspective of the implementation landscape in LMICs. There is a need for consistency in measures in order to accurately assess the feasibility of integrated CVD-HIV care in LMICs.

INTRODUCTION:Given constrained funding for Human Immunodeficiency Virus (HIV) programs across Sub-Saharan Africa, delivering services efficiently is paramount. Voluntary medical male circumcision (VMMC) is a key intervention that can substantially reduce heterosexual transmission-the primary mode of transmission across the continent. There is limited research, however, on what factors may contribute to the efficient and high-quality execution of such programs. METHODS:We analyzed a multi-country, multi-stage random sample of 108 health facilities providing VMMC services in sub-Saharan Africa in 2012 and 2013. The survey collected information on inputs, outputs, process quality and management practices from facilities providing VMMC services. We analyzed the relationship between management practices, quality (measured through provider vignettes) and efficiency (estimated through data envelopment analysis) using Generalized Linear Models and Mixed-effects Models. Applying multivariate regression models, we assessed the relationship between management indices and efficiency and quality of VMMC services. RESULTS:Across countries, both efficiency and quality varied widely. After adjusting for type of facility, country and scale, performance-base funding was negatively correlated with efficiency -0.156 (p < 0.05). In our analysis, we did not find any significant relationships between quality and management practices. CONCLUSIONS:No significant relationship was found between process quality and management practices across 108 VMMC facilities. This study is the first to analyze the potential relationships between management and service quality and efficiency among a sample of VMMC health facilities in sub-Saharan Africa and can potentially inform policy-relevant hypotheses to later test through prospective experimental studies.

BackgroundThe World Health Organization has recommended the introduction of HPV vaccines into national immunization programme (NIP), but vaccination coverage remains low worldwide. We assessed the coverage and the parental acceptance of female and male HPV vaccination in Brazil after its introduction into the NIP.MethodsWe conducted a random-digit-dial survey of parents in seven major Brazilian cities from July-2015 to October-2016. A knowledge, attitude and practices questionnaire was developed and validated by expert analysis, semantic analysis, and pre-testing.Results826 out of 2,324 (35.5%) eligible parents completed the interview. Parental acceptance of the HPV vaccine for daughters and sons 18 years of age or less was high (92% and 86%, respectively). Parents refusing vaccination were less likely to know that: HPV is sexually transmitted and causes genital warts, HPV vaccination is more beneficial before sexual debut, and HPV vaccine reactions are minor, and they were more likely to believe HPV vaccination can cause severe adverse events. Parents accepting HPV vaccine for daughters but not forsons were more likely to ignore that the vaccine is recommended for boys. Attitudes associated with HPV vaccine acceptance included: general belief in vaccines, trust in the NIP and in the HPV vaccine efficacy. Among girls eligible for HPV vaccination through the NIP, 58.4% had received a two-dose scheme and 71.1% at least one dose. "No vaccination/missed vaccination at school" was the most common reason for missed HPV vaccination in theNIP.ConclusionsOne year after introduction in the NIP, most parents surveyed in Brazil accepted HPV vaccination for their daughters and sons. Low coverage in the NIP seemed to be due to challenges in adolescent vaccine delivery and HPV vaccination barriers at health-care centers, rather than to vaccine refusal.

This study evaluates the use of a mental health mobile clinic to overcome two major challenges to the provision of mental healthcare in resource-limited settings: the shortage of trained specialists; and the need to improve access to safe, effective, and culturally sound care in community settings. Employing task-shifting and supervision, mental healthcare was largely delivered by trained, non-specialist health workers instead of specialists. A retrospective chart review of 318 unduplicated patients assessed and treated during the mobile clinic's first two years (January 2012 to November 2013) was conducted to explore outcomes. These data were supplemented by a quality improvement questionnaire, illustrative case reports, and a qualitative interview with the mobile clinic's lead community health worker. The team evaluated an average of 42 patients per clinic session. The most common mental, neurological, or substance abuse (MNS) disorders were depression and epilepsy. Higher follow-up rates were seen among those with diagnoses of bipolar disorder and neurological conditions, while those with depression or anxiety had lower follow-up rates. Persons with mood disorders who were evaluated on at least two separate occasions using a locally developed depression screening tool experienced a significant reduction in depressive symptoms. The mental health mobile clinic successfully treated a wide range of MNS disorders in rural Haiti and provided care to individuals who previously had no consistent access to mental healthcare. Efforts to address these common barriers to the provision of mental healthcare in resource-limited settings should consider supplementing clinic-based with mobile services.

BackgroundThe World Health Organization has recommended the introduction of HPV vaccines into national immunization programme (NIP), but vaccination coverage remains low worldwide. We assessed the coverage and the parental acceptance of female and male HPV vaccination in Brazil after its introduction into the NIP.MethodsWe conducted a random-digit-dial survey of parents in seven major Brazilian cities from July-2015 to October-2016. A knowledge, attitude and practices questionnaire was developed and validated by expert analysis, semantic analysis, and pre-testing.Results826 out of 2,324 (35.5%) eligible parents completed the interview. Parental acceptance of the HPV vaccine for daughters and sons 18 years of age or less was high (92% and 86%, respectively). Parents refusing vaccination were less likely to know that: HPV is sexually transmitted and causes genital warts, HPV vaccination is more beneficial before sexual debut, and HPV vaccine reactions are minor, and they were more likely to believe HPV vaccination can cause severe adverse events. Parents accepting HPV vaccine for daughters but not forsons were more likely to ignore that the vaccine is recommended for boys. Attitudes associated with HPV vaccine acceptance included: general belief in vaccines, trust in the NIP and in the HPV vaccine efficacy. Among girls eligible for HPV vaccination through the NIP, 58.4% had received a two-dose scheme and 71.1% at least one dose. "No vaccination/missed vaccination at school" was the most common reason for missed HPV vaccination in theNIP.ConclusionsOne year after introduction in the NIP, most parents surveyed in Brazil accepted HPV vaccination for their daughters and sons. Low coverage in the NIP seemed to be due to challenges in adolescent vaccine delivery and HPV vaccination barriers at health-care centers, rather than to vaccine refusal.

Background: The citizens' perspectives on health care are central to the assessment of the health care situation and to regional development. In Germany, however, strategic goals for health care delivery are planned based on population statistics and partly on regional morbidity. Saxony is a German federal state with high average age and low density of physicians which makes the population perspective on quality of health care especially intersting. No existing panel surveys cover issues related to the perceived quality of health care delivery on a regional level in Germany., Aim: We aim to conduct a longitudinal panel study of the perceived health status and perceived quality of health care of the Saxon citizens as a basis for the systematic derivation of health care goals/measures and target group-specific, regionally suitable prevention measures., Methods: With an anticipated 15% response rate, 15,000 potential participants have to be contacted to achieve a calculated sample size of about 2,250 participants. The questionnaire will be circulated every other year with the option for adaptations depending on insights of each panel wave. The study protocol was approved by the local ethics committee of the Technische Universität Dresden, Germany (ethical approval code BO-EK-320072022) and has been registered at the German Clinical Trials Register as the German WHO primary registry (study registration number DRKS00031229)., Discussion and Outlook: The results are intended to identify gaps in health care and to develop patient-centered health care goals for the region together with stakeholders in Saxon health care planning. At the same time, longitudinal data allow mapping of perceived health status and perceived health care trends., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: JS reports institutional grants for investigator-initiated research from the German GBA, the BMG, BMBF, EU, Federal State of Saxony, Novartis, Sanofi, ALK, and Pfizer. He also participated in advisory board meetings as a paid consultant for Sanofi, Lilly, and ALK. JS serves the German Ministry of Health as a member of the Sachverständigenrat Gesundheit und Pflege. MK reports institutional grants for investigator-initiated research from the German GBA, the EU, BMBF and the DFG. LH reports fees from the Volkswagen Foundation and from Thieme. LR and TH report fees from the aQua-Institut. These reports are unrelated to this study. This does not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: © 2024 Harst et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: The delivery of rehabilitation services for hard-to-reach populations (e.g., refugees) is highly complex. There is a need for evidence-based approaches to deliver physiotherapy (PT) or occupational therapy (OT) services to this underserved group., Objectives: The purpose of this scoping review was to identify PT and OT service delivery models that have been implemented, for populations typically identified as hard-to-reach and their associated health outcomes., Eligibility Criteria: Articles were eligible if they described PT and/or OT services for hard-to-reach populations. There were no restrictions on study design., Study Selection: Six electronic databases (AMED, CINAHL, MEDLINE, EMBASE, Healthstar, and PsycINFO) were searched from January 2000 to June 2023. Articles were screened in duplicate by two independent reviewers, and conflicts were resolved by consensus., Results: Twenty-one articles with variable sample sizes (min, max n = 3 to 237) were included and detailed PT and/or OT services for immigrants/migrants, refugees, hard-to-reach veterans, people experiencing homelessness, lower incomes, trauma/torture, and those living in rehabilitation-deficient areas. Common rehabilitation needs (e.g., clinician to client connectivity), barriers (e.g., high transportation costs) and facilitators (e.g., encouragement) were identified among the various populations, mainly due to intersecting identities such as those who are both traumatized and refugees. Unique factors pertaining to the PT and OT services were also identified in some groups, including access to child and family services for people experiencing homelessness., Conclusions: Despite common and individual needs, barriers, and facilitators in hard-to-reach groups in the literature, there is a need for studies with larger sample sizes, rigorous methodology and a conscious effort to publish the results of interventions to generate stronger recommendations for practice., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Noguchi et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: With the increasing demand on the global health system and the presence of persistent healthcare disparities, it becomes imperative to utilize the full potential of the healthcare workforce, including allied health professionals (AHPs). To date, no review has mapped the literature on clinical care ratios (CCRs) for AHPs. This information is vital in guiding future work-force planning to address healthcare issues such as understaffed and at capacity hospitals. This scoping review mapped available evidence to offer a comprehensive insight into current AHP CCRs, enabling evidence-based decision-making that ensures optimal care and enhanced system efficiency., Methods: The scoping review was undertaken using the 'Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews' (PRISMA-ScR). The search was conducted using Ovid (MEDLINE, Embase, Emcare, PsycINFO), CINAHL, the Cochrane Library, Scopus, PEDro, OTseeker and grey literature. Two reviewers independently screened records, following which data extraction was completed for the included studies. Descriptive synthesis was used to summarize the data., Results: Of the 7670 records identified, 18 studies were included in this review. Whilst there was variability between AHPs on direct clinical time spent with patients, considerable amount of time was also spent on activities beyond direct clinical care. To offset this, literature highlights opportunities for allied health assistants and students to undertake tasks which would free-up AHPs to undertake more direct and higher-level tasks. However, limitations of findings (variability in measurement, lack of coverage of some professions) limits generalisability., Conclusion: While the literature highlights considerable variability in CCRs among different AHP disciplines, it does appear nearly a nearly a third of time spent by AHPs are on tasks that are beyond direct clinical care. Future research could explore new workforce models which would free-up AHPs to undertake more direct and higher-level tasks., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Brown et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Type 2 diabetes is a major global public health challenge, particularly in the African region. Though evidence exists on pharmacological agents and non-pharmacological interventions in maintaining blood glucose concentration, the healthcare systems' ability to meet patients' needs may be inadequate. The management of non-communicable diseases, particularly diabetes, has been postulated to depend on functioning health systems. This systematic review will, therefore, summarize the current evidence on existing health systems interventions in primary health settings for type 2 diabetes care and health outcomes in West Africa and will explore the impact of these system-level interventions on service availability, accessibility and quality, as well as individualized outcomes such as glycemic control, disease awareness and treatment adherence. The review will be conducted according to the reporting guidance in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P). The health system framework by Witter et al., 2019 will guide the system-level interventions and the search strategy to be explored in this review. This framework was designed to integrate the six building blocks of the World Health Organization (WHO) health systems framework and it delineates how they work synergistically to improve specific health outcomes. We will search the following databases PubMed, Google Scholar and Cumulated Index to Nursing and Allied Health Literature (CINAHL) between January 2000 to January 2024. We will also search Cairn.info for articles published between January 2005 to January 2024. The Cochrane Collaboration tool for assessing Risk of Bias will be implemented in each included study. We will conduct a narrative synthesis and make comparisons across findings using Excel-generated tables. In Conclusion, this systematic review will outline the existing system-level interventions that aim to or already improve type 2 diabetes services in primary health settings in West Africa and will offer suggestions for the strengthening and co-production of successful interventions that can be generalized to the entire sub-region., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Bondzie et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Responding to the COVID-19 pandemic has presented an unprecedented challenge to health systems, with countries needing to balance the demands of responding directly to the pandemic, while simultaneously continuing provision of essential health services. This study aimed to explore the impact of COVID-19 on essential healthcare services in Addis Ababa, Ethiopia., Methods: A facility-based retrospective study was undertaken in 30 health centers in Addis Ababa which were selected using simple random sampling. Secondary data were extracted for 22 indicators on maternal and child health, communicable and non-communicable diseases, and outpatient services for the period spanning between July 2019 and October 2020. These indicators were selected based on the WHO operational guidance on maintaining essential health services during an outbreak guide, essential packages of health services in Ethiopia and expert consultation. The difference in the trends of services before and during COVID-19 was compared using linear-by-linear tests and the difference of magnitude across the indicators was compared using Autoregressive Integrated Moving Average (ARIMA) interrupted time series analysis at a 5% significance level., Results: Overall, more than 1.7 million people visited the studied facilities for outpatient services, and 18,325 mothers attended skilled delivery in the study period. The present study found that the mean number of patients treated for TB declined by 35 patients (β: -34.62; 95%CI: -50.29, -18.95) compared to the pre-COVID-19 era while the number of new patients enrolled for ART decreased by 71 patients (β: -70.62; 95%CI: -107.19, -34.05). Regarding maternal health services, the number of women who received post-natal care decreased by about 215 mothers (β: -214.87; 95%CI: -331.57, -98.17). Similarly, the mean number of clients served at inpatient services declined by 34 (β: -33.72; 95%CI: -68.55, 1.05). On the other hand, the mean number of patients screened for diabetes and hypertension during the pandemic increased by more than 1014 (β: 1014.5; 95%CI: 103.07, 1925.92) and 610 patients (β: 611.21; 95%CI: 302.42, 919.99), respectively. However, changes with regard to antenatal care, skilled birth delivery, and children immunization services did not show a statistically significant change after COVID-19 was reported in Ethiopia., Conclusion: Despite the notable efforts to sustain essential health services amidst the COVID-19 pandemic, our study revealed that there were disruptions in these services. This reinforces the need to adapt strategies to ensure sustainable provision of essential health services when pandemics of COVID19 magnitude cause disruptions of the health services., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Abera et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Musculoskeletal (MSK) conditions, particularly shoulders, knees, and the low back issues, place a significant burden on individuals, society, and healthcare systems. There is a lack of attention to negative health effects impacting patients because of their interactions to access appropriate diagnostics, assessments, and treatments. This scoping review intends to search and synthesize peer-reviewed evidence on the negative health impacts associated with navigating the healthcare system for MSK care. A scoping review will be conducted following the PRISMA guidelines for Scoping Reviews and Arksey and O'Malley's 5-step process. Six databases will be searched with no time or geographic limits. Included articles must meet all the following criteria: 1) the patients must be adults, 2) patients must be seeking care for their knee, low-back, or shoulder condition, 3) interacted with the healthcare system, and 4) experienced health impacts due to navigating the healthcare system. Information from each article will be charted in a pre-determined extraction. This protocol aims to share our methods ahead of analysis to increase rigour and transparency. The scoping review results will better elucidate the health impacts of the inaccessibility of high-quality care for MSK conditions. The findings also aim to inform the development of patient-centered outcomes to evaluate alterations to the current MSK pathways., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Jessiman-Perreault et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

The aim of this research is to investigate the role of servicescape on re-patronage and recommended intention through pleasure feeling and satisfaction in healthcare settings that put substantial contribution in the process of healthcare service delivery. Data were collected through cross-sectional convenience sampling via a self-administered survey questionnaire from 431 clinical outpatients who revisit the same hospital of metropolitan areas of Punjab, Pakistan. Structural Equation Modeling (SEM) was carried out for path analysis through AMOS (24.0 V), while statistical measures were analyzed using SPSS (25.0 V). The present study results revealed that patients' intention optimistically triggered through partial mediation and affirm the direct and indirect association with servicescape. It also revealed that patient-recommended and re-patronage intentions to visit the clinic were statistically substantial and positively influenced by intervening constructs of pleasure feeling and satisfaction. Additionally, it is found that servicescape and pleasure feeling contributed to 30% change in satisfaction. Moreover, pleasure feeling, and satisfaction contributed to 50% change in re-patronage and 31% change in recommendation intention of the patients. The current study findings contribute significantly to servicescape literature from a theatrical perspective and reevaluate the patterns and operations in healthcare. It also helps managers and administrators of private hospitals to make strategies to increase patient satisfaction., Competing Interests: NO authors have competing interests., (Copyright: © 2024 Rauf et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background and Objective: Transgender and gender-diverse (TGD) persons experience health inequities compared to their cisgender peers, which is in part related to limited evidence informing their care. Thus, we aimed to describe the literature informing care provision of TGD individuals., Data Source, Eligibility Criteria, and Synthesis Methods: Literature cited by the World Professional Association of Transgender Health Standards of Care Version 8 was reviewed. Original research articles, excluding systematic reviews (n = 74), were assessed (n = 1809). Studies where the population of interest were only caregivers, providers, siblings, partners, or children of TGD individuals were excluded (n = 7). Results were synthesized in a descriptive manner., Results: Of 1809 citations, 696 studies met the inclusion criteria. TGD-only populations were represented in 65% of studies. White (38%) participants and young adults (18 to 29 years old, 64%) were the most well-represented study populations. Almost half of studies (45%) were cross-sectional, and approximately a third were longitudinal in nature (37%). Overall, the median number of TGD participants (median [IQR]: 104 [32, 356]) included in each study was approximately one third of included cisgender participants (271 [47, 15405]). In studies where both TGD and cisgender individuals were included (n = 74), the proportion of TGD to cisgender participants was 1:2 [1:20, 1:1]. Less than a third of studies stratified results by sex (32%) or gender (28%), and even fewer included sex (4%) or gender (3%) as a covariate in the analysis. The proportion of studies with populations including both TGD and cisgender participants increased between 1969 and 2023, while the proportion of studies with study populations of unspecified gender identity decreased over the same time period., Conclusions: While TGD participant-only studies make up most of the literature informing care of this population, longitudinal studies including a diversity of TGD individuals across life stages are required to improve the quality of evidence., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Pattar et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction: The pursuit of Equity, Diversity and Inclusion (EDI) in healthcare education has garnered significant attention in recent years, reflecting a broader societal imperative for equitable healthcare delivery. However, existing curricula within geriatric healthcare education may not adequately address these diverse needs within their educational frameworks, inadvertently resulting in disparities in care delivery and outcomes. Within the realm of geriatric healthcare, addressing EDI is particularly crucial due to the diverse needs of older adult populations and the imperative for healthcare professionals to deliver culturally humble care. This review provides a comprehensive overview of strategies and curricular strategies, actions and/or initiatives to promote EDI within geriatric healthcare professional education., Methods: This paper presents a protocol for a forthcoming scoping review. The methodology for this scoping review adheres to the framework outlined in the Joanna Briggs Institute (JBI) Manual, encompassing four main stages: (1) formulation of a search strategy, (2) screening and selection of evidence, (3) data extraction, and (4) analysis. We will conduct a comprehensive search of peer-reviewed and empirical literature. Additionally, we will explore the reference lists of included studies to identify any relevant sources. The synthesis of findings will be conducted through a narrative approach. Reporting of the methods and results will adhere to the guidelines provided by the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR)., Discussion: Healthcare professionals must possess the knowledge, skills, and attitudes necessary to deliver culturally humble care that respects and responds to diverse older adults' unique needs and preferences. The review aims to fill a crucial gap in the literature by providing a comprehensive overview of strategies and curricular interventions designed to promote EDI within geriatric healthcare professional education. By mapping these strategies, actions and/or initiatives, the review seeks to identify trends, challenges, and opportunities for advancing EDI within geriatric care. The forthcoming review serves as a call to action for educators, healthcare institutions, and decision makers to prioritize EDI within geriatric healthcare education. The review identifies effective strategies and interventions for promoting EDI, providing actionable insights to inform the development of inclusive curricula, training programs, and institutional policies, which can contribute to cultivating a healthcare workforce better equipped to address the complex and evolving needs of aging populations equitably and compassionately., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Kokorelias et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Diabetic foot ulcers are challenging to heal, increase the risk of lower extremity amputation, and place a significant burden on patients, families, and healthcare systems. Prioritizing preventive interventions holds the promise of reducing patient suffering, lowering costs, and improving quality of life. This study describes a scoping review protocol that will be used to delineate the preventive interventions for diabetic foot ulcers employed in different healthcare settings., Methods: The scoping review methodology was formulated in accordance with the PRISMA extension guidelines for scoping reviews and informed by the procedural insights provided by the JBI methodology group. Studies with participants diagnosed with type 1 and type 2 diabetes, aged 18 years or older, without an active ulcer at baseline, and studies of preventive interventions for foot ulcers in various healthcare settings will be screened. The search strategy was developed in collaboration with a research librarian using the PRESS checklist and no time or language limitations were applied. Data will be analyzed and summarized descriptively, including characteristics of studies, participants, and interventions., Discussion: Understanding the strategies and gaps in diabetic foot ulcer prevention is critical. The literature can provide valuable insights for developing tailored interventions and strategies to effectively address these gaps, potentially accelerating progress toward improved outcomes in diabetic foot ulcer prevention., Review Registration: Open Science Framework DOI 10.17605/OSF.IO/FRZ97 [June 19, 2023]., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Araújo et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

OBJECTIVES:To determine if integration of family planning (FP) and HIV services led to increased use of more effective contraception (i.e. hormonal and permanent methods, and intrauterine devices) and decreased pregnancy rates. DESIGN:Cohort analysis following cluster randomized trial, when the Kenya Ministry of Health led integration of the remaining control (delayed integration) sites and oversaw integrated services at the original intervention (early integration) sites. SETTING:Eighteen health facilities in Kenya. SUBJECTS:Women aged 18-45 receiving care: 5682 encounters at baseline, and 11628 encounters during the fourth quarter of year 2. INTERVENTION:"One-stop shop" approach to integrating FP and HIV services. MAIN OUTCOME MEASURES:Use of more effective contraceptive methods and incident pregnancy across two years of follow-up. RESULTS:Following integration of FP and HIV services at the six delayed integration clinics, use of more effective contraception increased from 31.7% to 44.2% of encounters (+12.5%; Prevalence ratio (PR) = 1.39 (1.19-1.63). Among the twelve early integration sites, the proportion of encounters at which women used more effective contraceptive methods was sustained from the end of the first to the second year of follow-up (37.5% vs. 37.0%). Pregnancy incidence including all 18 integrated sites in year two declined in comparison to the control arm in year one (rate ratio: 0.72; 95% CI 0.60-0.87). CONCLUSIONS:Integration of FP services into HIV clinics led to a sustained increase in the use of more effective contraceptives and decrease in pregnancy incidence 24 months following implementation of the integrated service model. TRIAL REGISTRATION:ClinicalTrials.gov NCT01001507.

Losses to follow-up (LTFU) remain an important programmatic challenge. While numerous patient-level factors have been associated with LTFU, less is known about facility-level factors. Data from the East African International epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium was used to identify facility-level factors associated with LTFU in Kenya, Tanzania and Uganda. Patients were defined as LTFU if they had no visit within 12 months of the study endpoint for pre-ART patients or 6 months for patients on ART. Adjusting for patient factors, shared frailty proportional hazard models were used to identify the facility-level factors associated with LTFU for the pre- and post-ART periods. Data from 77,362 patients and 29 facilities were analyzed. Median age at enrolment was 36.0 years (Interquartile Range: 30.1, 43.1), 63.9% were women and 58.3% initiated ART. Rates (95% Confidence Interval) of LTFU were 25.1 (24.7-25.6) and 16.7 (16.3-17.2) per 100 person-years in the pre-ART and post-ART periods, respectively. Facility-level factors associated with increased LTFU included secondary-level care, HIV RNA PCR turnaround time >14 days, and no onsite availability of CD4 testing. Increased LTFU was also observed when no nutritional supplements were provided (pre-ART only), when TB patients were treated within the HIV program (pre-ART only), and when the facility was open ≤4 mornings per week (ART only). Our findings suggest that facility-based strategies such as point of care laboratory testing and separate clinic spaces for TB patients may improve retention.

This paper examines the role of temporality in the negotiation of unplanned adaptive tasks that were part of the health system response to the Covid-19 pandemic in Colombia. While research has been carried out on the temporal aspects of emergency preparedness, we argue that there is an empirical gap concerning how health care organizations responded with temporal urgency to Covid-19. The dataset (118 interviews) from which a subset of interviews were analysed for this paper was collected during the first wave of the pandemic in Colombia in 2020. Interviewees included representatives of national and regional governments, public hospitals and private clinic managers, clinicians, including physicians and nurses, laboratory directors, and academics. Narratives of two tasks are presented: reconfiguring clinical laboratories to expand the testing capacity for Covid-19 and increasing intensive care unit capacity for patients hospitalized with Covid-19. Through thematic analysis of the navigation of these tasks, the concept of "temporal shifts", which signifies how organizations use time as a resource (analogous experiences, future projections) to negotiate unplanned service changes, is developed. This study highlights how powerful stakeholders deploy past and future projections to influence others´ perceptions in the negotiation of temporal shifts: a type of change that differs from the incremental and planned types described in previous organizational literature on temporality. This shift was initiated by rapid task delegation via organizational hierarchy, but accomplished through pressured, improvised actions at the operational level. The policy and practice implications we suggest relate to addressing social and organizational effects, including consequences for stakeholder engagement and staff wellbeing, generated by organizational leaders making decisions under "time stress"., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Turner, Fernandez. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Hospital discharge is a pivotal point in healthcare delivery, impacting patient outcomes and resource utilisation. Ineffective discharge processes contribute to unplanned hospital readmissions. This study explored hospital discharge process from the perspectives of patients, caregivers, and healthcare staff. Qualitative data were collected through semi-structured interviews with adult patients being discharged home from a medical ward, their caregivers, and healthcare staff at an Australian hospital. Thematic analysis followed established guidelines for qualitative research. A total of 65 interviews and 21 structured observations were completed. There were three themes: i) Communication, ii) System Pressure, and iii) Continuing Care. The theme 'Communication' highlighted challenges and inconsistencies in notifying patients, caregivers, and staff about discharge plans, leading to patient stress and frustration. Information overload during discharge hindered patient comprehension and satisfaction. Staff identified communication gaps between teams, resulting in uncertainty regarding discharge logistics. The theme 'System Pressure' referred to pressure to discharge patients quickly to free hospital capacity occasionally, even in the face of inadequate service provision on weekends and out-of-hours. The 'Continuing Care' theme drew attention to gaps in patient understanding of follow-up appointments, underscoring the need for clearer post-discharge instructions. The lack of structured systems for tracking referrals and post-discharge care coordination was also highlighted, potentially leading to fragmented care. The findings resonate with international literature and the current emphasis in Australia on improving communication during care transitions. Furthermore, the study highlights the tension between patient-centred care and health service pressure for bed availability, resulting in perceptions of premature discharges and unplanned readmissions. It underscores the need for strengthening community-based support and systems for tracking referrals to improve care continuity. These findings have implications for patient experience and safety and suggest the need for targeted interventions to optimise the discharge process., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Omonaiye et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Smoking is a leading cause of preventable morbidity and mortality globally. During the COVID-19 pandemic, Smoking Cessation (SC) services faced many challenges, including lockdown and social distancing restrictions. Consequently, SC services had to adapt to the challenges in different ways or halt delivery. This research evaluated the impact of COVID-19 on the delivery and outcomes of SC services. This was achieved by comparing service delivery and outcomes pre-COVID-19 and during the pandemic and drawing insights for the delivery of SC services post-pandemic. Secondary analysis was performed on the data of 11,533 participants who attended the One Life Suffolk (OLS) SC services pre- and during the COVID-19 pandemic. A total of 4923 and 6610 participants attended SC services pre-COVID-19 and during COVID-19 respectively. Fifty-four percent of participants achieved quit status at week-4 while attending the SC services during the COVID-19 pandemic, compared with 46% pre-COVID-19, (X2(1) = 38.2, p-value<0.001). Participants who attended the SC services during the COVID-19 period were 1.7 times more likely to achieve quit status at week-4 than pre-COVID-19. However, the proportion of participants lost-to-follow-up (LTF) was significantly higher during the COVID-19 period (11%) compared to pre-COVID-19 (7%), (X2(1) = 51.4, p-value <0.001). There was an increased participation and quit rate during the pandemic for modified, remotely delivered SC services indicating successful delivery of remote services during the pandemic. Although switching from face-to-face to online helped some smokers to access the service at a time of motivational readiness, despite the COVID-19 restrictions, some smokers could not access or use some aspects of the remote delivery due to a lack of internet access, poor digital literacy, no peer support and no commitment to a group during face-to-face sessions, contributing to an increased rate of LTF. Posing a major challenge to SC services delivery, COVID-19 compelled OLS SC services to adapt and be more innovative in their delivery. SC services need to continue to evolve and adapt by applying the lessons learnt during the pandemic in terms of flexibility and person-centered delivery given what did and did not work well for different demographics within the population., Competing Interests: All authors of this article have read the journal’s policy. Dr Windi Marwa and Dr Claire Griffiths have no competing interests. Competing interests for other authors are as follows: Prof. Carlton Cooke is an employee of Leeds Beckett University and is a board member of MoreLife; Caroline Marshall is an employee of MoreLife; Prof. Paul Gately is an employee of Leeds Beckett University and CEO and shareholder of MoreLife; Dr Sophie Edwards is an employee of MoreLife and a Leeds Beckett University Associate Staff member. OneLife Suffolk was a partnership between Leeds Beckett University and MoreLife, commissioned by Suffolk County Council to deliver integrated healthy lifestyles services, including smoking cessation services. This does not alter our adherence to all the PLOS ONE policies., (Copyright: © 2024 Marwa et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Differentiated service delivery models have been developed to accommodate the rising number of stable antiretroviral therapy clients and to maintain improvements in health outcomes and care retention. Ethiopia adopted the appointment spacing model and has had notable successes in implementing it. However, with the implementation of the six multi-month scripting/appointment spacing model in Ethiopia, little is known about the uptake and its associated factors. Therefore, this study aimed to assess the uptake and associated factors of the six multi-month scripting/appointment spacing differentiated service delivery model of care among stable clients on antiretroviral therapy in Southern Ethiopia., Methods: A hospital-based cross-sectional study was conducted among 419 stable clients on antiretroviral therapy in southern Ethiopia from June 22 to September 29, 2023. A systematic sampling technique was used to select the study participants. Using a structured questionnaire, socio-demographic, health service delivery, behavioral, and clinical-related data were collected. The collected data were entered into Epi Data version 3.1 and analyzed using Stata version 14. Variables with a P-value <0.05 in the multivariable logistic analysis were considered statistically significant. Multicollinearity and model fitness were checked using the variance inflation factor and the Hosmer and Lemeshow goodness of fit tests, respectively., Results: The uptake of the six multi-month scripting/appointment spacing differentiated service delivery model of care was 63.25% (95% confidence interval (CI): 58.61%, 67.88%). Missed appointment (Adjusted Odds Ratio (AOR): 1.91 (95% CI: 1.13, 3.25)), distance to antiretroviral therapy facility (AOR: 2.90 (95% CI: 1.67, 5.04)), duration on antiretroviral therapy (AOR: 2.21 (95% CI: 1.34, 3.64)), and intermediate social support (AOR: 2.02 (95% CI: 1.29, 3.17)) and strong social support (AOR: 2.71 (95% CI: 1.23, 5.97)) were factors significantly associated with the uptake., Conclusion: The uptake of six multi-month scripting/appointment spacing differentiated service delivery models of care was six out of ten clients on antiretroviral therapy. To further improve the uptake, a precise intervention on the identified associated factor is required., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Merid et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Parents of neonates with life-threatening conditions and professionals, bear the burden of making complex decisions. Parents may not be fully involved in decision-making, and there is a paucity of evidence regarding the influence of social context on parents' participation. We aimed to explore factors that extended beyond the healthcare system and impacted parents' participation in decision-making for neonates with life-threatening conditions., Materials and Methods: This qualitative research was carried out in 2019 in four level-III Iranian NICUs, (neonatal intensive care units) where twenty-three face-to-face semi-structured interviews were conducted, transcribed, and analyzed using a conventional content analysis technique. Interviews were condensed into meaningful units during the coding phase, resulting in 206 open codes. These codes were then categorized into eleven categories based on commonalities and distinctions. This iterative process continued until 4 main subcategories were established., Results: The main categories and sub-categories were "unmodified regulations according to the neonatology advances" (lack of regulations to modify ineffective treatments, lack of a legally documented do not resuscitate order, lack of a defined regional neonatal viability threshold, and lack of maternal guardianship of child medical care), "deficiencies of the health insurance system" (covering the cost of ineffective treatments and lack of insurance covering for palliative care services), "treatment-oriented culture in society" (expecting a miracle for medical science, difficult acceptance of neonatal death and difficult acceptance of home death), and "physician-oriented culture in society" (excessive respect for physicians' decision-making eligibility and social position of physicians)., Conclusion: The findings revealed concepts surrounding parents' participation in decision-making for life-threatening conditions neonates are influenced by social, legal, cultural, and financial aspects. To bridge the gap between healthcare professionals' attitudes and cultural and religious beliefs, fatwas, and laws, a collaborative approach is necessary. To address the complex challenges of decision-making for these neonates, involving stakeholders like clinicians, legal experts, Islamic scholars, sociologists, jurists, judges, and medical ethicists is crucial for modifying laws to align with neonatology advancements., Competing Interests: The authors have no financial relationships relevant to this article to disclose.” “Potential Conflicts of Interest: The authors have no conflicts of interest relevant to this article to disclose.” “Funding: none., (Copyright: © 2024 Oskouie et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Healthcare systems around the globe are facing challenges. There are increasing demands and costs at the same time as a diminishing health workforce. Without change, healthcare will become unsustainable. The Dutch government is searching for solutions, one of which is relocating healthcare. Relocating healthcare from expensive institutions to sites closer to patients' homes is an important part of this. This relocation is expected to reduce costs and lessen shortages of personnel. However, although citizens have an important stake in this, little is known about how they think about this topic. This research aims at investigating citizens' perspectives on relocating care., Methods: In December 2021, three open-ended questions were sent to 1,500 members of Nivel's Dutch Healthcare Consumer Panel, 796 respondents responded. In addition, two citizen platforms were organised in March and April 2022. A total of 23 citizens participated., Results: Our results indicated that the following aspects are important for citizens in healthcare delivery: being treated by someone with expertise in the area of their need, familiarity with the healthcare provider and the treatment of less complex care close to home. When certain conditions are met, citizens prefer treatment for less complex care from their general practitioner rather than in a hospital. The most important condition is that the general practitioner has the right expertise regarding their health question. The willingness to relocate care from the general practitioner to other healthcare providers or to self-care is also present. One of the problems, however, is that citizens often do not know to which healthcare provider they should go or what they should do to increase self-care., Conclusion: From a citizens' perspective, relocating care is an acceptable solution for keeping healthcare sustainable in the future, provided that certain conditions are met., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Damen et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Physical activity is important in the self-management of long-term conditions (LTCs). However, implementing physical activity into clinical practice is challenging, due to complex barriers including access to programmes, time pressures, and transport costs, for people with comorbidities, managing multiple responsibilities. Various digital tools exist to overcome these barriers and support wide-scale implementation to help people stay physically active. We explored the experiences, needs and preferences of healthcare professionals and commissioners, regarding the use of digital tools to support people with LTCs to self-manage using physical activity. This included barriers and facilitators to implementing digital tools to support people with LTCs in NHS settings. Semi-structured interviews were conducted (April 2021 to January 2022) in Wessex, southern England, UK. Purposive sampling was used to recruit general practitioners and healthcare professionals, and convenience sampling to recruit commissioners (n = 15). Transcripts were coded to develop conceptual themes allowing comparisons between and among perspectives, with the Normalisation Process Theory (NPT)'s four constructs used to aid interpretation. Results showed that most digital tools supporting physical activity for LTCs, are not well implemented clinically. Current digital tools were seen to lack condition-specificity, usability/acceptability evidence-base, and voluntary sector involvement (i.e., NPT: coherence or 'making sense'). Healthcare professionals and commissioners were unlikely to engage with use of digital tools unless they were integrated into health service IT systems and professional networks (i.e., NPT: cognitive participation), or adaptable to the digital literacy levels of service users and staff (i.e., NPT: collective action-needs for implementation). In practice, this meant being technically, easy to use and culturally accessible (i.e., NPT: collective action-promoting healthcare work). COVID-19 changed professional attitudes towards digital tools, in that they saw them being viable, feasible and critical options in a way they had not done before the pandemic. Implementation was also influenced by endorsement and trustworthiness enhancing the perception of them as secure and evidence-based (i.e., NPT: reflective monitoring). Our findings highlight that consideration must be given to ensuring that digital tools are accessible to both healthcare professionals and patients, have usability/acceptability, and are adaptable to specific LTCs. To promote clinical engagement, digital tools must be evidence-based, endorsed by professional networks, and integrated into existing health systems. Digital literacy of patients and professionals is also crucial for cross-service implementation., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Gavin et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

The recent surge in Internet growth has significantly altered how residents obtain health information and services, underscoring the need to investigate its impact on healthcare perceptions. However, current studies often fail to distinguish between Internet use and involvement, as well as the diverse range of healthcare stakeholders, resulting in incomplete and inconsistent understanding. To address this, this study utilized data from the 2018 China Family Panel Study (CFPS 2018), categorizing attitudes toward healthcare into three dimensions: doctor trust, satisfaction with medical institutions, and perception of systemic healthcare issues. Employing propensity score matching (PSM) to control for thirteen confounding variables, this study examined the Internet's impact on public attitudes toward healthcare among similar demographic, psychological, and health-related variables. Results revealed that both Internet use and involvement affect residents' attitudes toward healthcare to some extent, with involvement having a more pronounced effect. While Internet use increased the perception of systemic healthcare issues, Internet involvement enhanced doctor trust, yet reduced satisfaction with medical institutions and exaggerated the perception of systemic healthcare issues. These findings have significant theoretical and practical implications. They enhance the comprehension of diverse levels and purposes of Internet use, thereby advancing our knowledge of its multi-faced influence on public attitudes toward healthcare. Furthermore, they offer insights for medical institutions to improve service quality, assist Internet media in optimizing information delivery, and illuminate the implications for residents who effectively use the Internet to assess health information., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Li et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Implementation of artificial intelligence systems for healthcare is challenging. Understanding the barriers and implementation strategies can impact their adoption and allows for better anticipation and planning. This study's objective was to create a detailed inventory of barriers to and strategies for AI implementation in healthcare to support advancements in methods and implementation processes in healthcare. A sequential explanatory mixed method design was used. Firstly, scoping reviews and systematic literature reviews were identified using PubMed. Selected studies included empirical cases of AI implementation and use in clinical practice. As the reviews were deemed insufficient to fulfil the aim of the study, data collection shifted to the primary studies included in those reviews. The primary studies were screened by title and abstract, and thereafter read in full text. Then, data on barriers to and strategies for AI implementation were extracted from the included articles, thematically coded by inductive analysis, and summarized. Subsequently, a direct qualitative content analysis of 69 interviews with healthcare leaders and healthcare professionals confirmed and added results from the literature review. Thirty-eight empirical cases from the six identified scoping and literature reviews met the inclusion and exclusion criteria. Barriers to and strategies for AI implementation were grouped under three phases of implementation (planning, implementing, and sustaining the use) and were categorized into eleven concepts; Leadership, Buy-in, Change management, Engagement, Workflow, Finance and human resources, Legal, Training, Data, Evaluation and monitoring, Maintenance. Ethics emerged as a twelfth concept through qualitative analysis of the interviews. This study illustrates the inherent challenges and useful strategies in implementing AI in healthcare practice. Future research should explore various aspects of leadership, collaboration and contracts among key stakeholders, legal strategies surrounding clinicians' liability, solutions to ethical dilemmas, infrastructure for efficient integration of AI in workflows, and define decision points in the implementation process., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Nair et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: The association between rurality of patients' residence and hospital experience is incompletely described. The objective of the study was to compare hospital experience by rurality of patients' residence., Methods: From a US Midwest institution's 17 hospitals, we included 56,685 patients who returned a post-hospital Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. We defined rurality using rural-urban commuting area codes (metropolitan, micropolitan, small town, rural). We evaluated the association of patient characteristics with top-box score (favorable response) for 10 HCAHPS items (six composite, two individual, two global). We obtained adjusted odds ratios (aOR [95% CI]) from logistic regression models including patient characteristics. We used key driver analysis to identify associations between HCAHPS items and global rating (combined overall rating of hospital and recommend hospital)., Results: Of all items, overall rating of hospital had lower odds of favorable response for patients from metropolitan (0.88 [0.81-0.94]), micropolitan (0.86 [0.79-0.94]), and small towns (0.90 [0.82-0.98]) compared with rural areas (global test, P = .003). For five items, lower odds of favorable response was observed for select areas compared with rural; for example, recommend hospital for patients from micropolitan (0.88 [0.81-0.97]) but not metropolitan (0.97 [0.89-1.05]) or small towns (0.93 [0.85-1.02]). For four items, rurality showed no association. In metropolitan, micropolitan, and small towns, men vs. women had higher odds of favorable response to most items, whereas in rural areas, sex-based differences were largely absent. Key driver analysis identified care transition, communication about medicines and environment as drivers of global rating, independent of rurality., Conclusions: Rural patients reported similar or modestly more favorable hospital experience. Determinants of favorable experience across rurality categories may inform system-wide and targeted improvement., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Fawad et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Community pharmacies are the first point of contact for most people seeking treatment for minor illnesses globally. In recent years, the role of community pharmacists has evolved, and they play a significant role in the delivery of public health interventions (PHIs) aimed at health promotion and prevention such as smoking cessation services, weight management services, HIV prevention, and vaccination. This review aims to explore the evidence on the factors that influence community pharmacists to take up the role of delivery of such interventions., Methods: Three electronic databases namely, Embase (1947-December 2023), Medline (1975-December 2023), and Scopus (1823-December 2023) were searched for relevant literature from the inception of the database to December 2023. Reference lists of included articles were also searched for relevant articles. A total of 22 articles were included in the review based on our inclusion and exclusion criteria. The data were analyzed and synthesized using a thematic approach to identify the factors that influence the community pharmacist's decision to take up the role of PHI delivery. Reporting of the findings was done according to the PRISMA checklist., Findings: The search identified 10,927 articles of which 22 were included in the review. The main factors that drive the delivery of PHIs by community pharmacists were identified as; training and continuous education, remuneration and collaboration with other healthcare professionals. Other factors included structural and workflow adjustments and support from the government and regulatory bodies., Conclusions: Evidence from this review indicates that the decision to expand the scope of practice of community pharmacists is influenced by various factors. Incorporating these factors into the design of policies and public health programs is critical for the successful integration of community pharmacists in the delivery of broader public health to meet the rising demand for health care across health systems., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Mumbi et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Many areas of healthcare are impacted by a paucity of research that is translatable to clinical practice. Research utilising real-world data, such as routinely collected patient data, may be one option to efficiently create evidence to inform practice and service delivery. Such studies are also valuable for exploring (in)equity of services and outcomes, and benefit from using non-selected samples representing the diversity of the populations served in the 'real world'. This scoping review aims to identify and map the published research which utilises routinely collected clinical healthcare data. A secondary aim is to explore the extent to which this literature supports the pursuit of social justice in health, including health inequities and intersectional approaches., Method: This review utilises Arksey and O'Malley's methodological framework for scoping reviews and draws on the recommended enhancements of this framework to promote a team-based and mixed methods approach. This includes searching electronic databases and screening papers based on a pre-specified inclusion and exclusion criteria. Data relevant to the research aims will be extracted from included papers, including the clinical/professional area of the topic, the source of data that was used, and whether it addresses elements of social justice. All screening and reviewing will be collaborative and iterative, drawing on strengths of the research team and responsive changes to challenges will be made. Quantitative data will be analysed descriptively, and conceptual content analysis will be utilised to understand qualitative data. These will be collectively synthesised in alignment to the research aims., Conclusion: Our findings will highlight the extent to which such research is being conducted and published, including gaps and make recommendations for future endeavours for real-world data studies. The findings from this scoping review will be relevant for practitioners and researchers, as well as health service managers, commissioners, and research funders., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Chadd et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Decentralised and evidence-informed health systems rely on managers and practitioners at all levels having sufficient 'decision space' to make timely locally informed and relevant decisions. Our objectives were to understand decision spaces in terms of constraints and enablers and outline opportunities through which to expand them in an understudied rural context in South Africa., Methods: This study examined decision spaces within Mpumalanga Province, using data and insights generated through a participatory action research process with local communities and health system stakeholders since 2015, which was combined with published documents and research team participant observation to produce findings on three core domains at three levels of the health system., Results: Although capacity for decision making exists in the system, accessing it is frequently made difficult due to a number of intervening factors. While lines of authority are generally well-defined, personal networks take on an important dimension in how stakeholders can act. This is expressed through a range of informal coping strategies built on local relationships. There are constraints in terms of limited formal external accountability to communities, and internal accountability which is weak in places for individuals and focused more on meeting performance targets set at higher levels and less on enabling effective local leadership. More generally, political and personal factors are clearly identified at higher levels of the system, whereas at sub-district and facility levels, the dominant theme was constrained capacity., Conclusions: By examining the balance of authority, accountability and capacity across multiple levels of the provincial health system, we are able to identify emergent decision space and areas for enlargement. Creating spaces to support more constructive relationships and dialogue across system levels emerges as important, as well as reinforcing horizontal networks to problem solve, and developing the capacity of link-agents such as community health workers to increase community accountability., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Witter et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Over the last decade, the strain on the English National Health Service (NHS) has increased. This has been especially felt by acute hospital trusts where the volume of admissions has steadily increased. Patient outcomes, including inpatient mortality, vary between trusts. The extent to which these differences are explained by systems-based factors, and whether they are avoidable, is unclear. Few studies have investigated these relationships. A systems-based methodology recognises the complexity of influences on healthcare outcomes. Rather than clinical interventions alone, the resources supporting a patient's treatment journey have near-equal importance. This paper first identifies suitable metrics of resource and demand within healthcare delivery from routinely collected, publicly available, hospital-level data. Then it proceeds to use univariate and multivariable linear regression to associate such systems-based factors with standardised mortality. Three sequential cross-sectional analyses were performed, spanning the last decade. The results of the univariate regression analyses show clear relationships between five out of the six selected predictor variables and standardised mortality. When these five predicators are included within a multivariable regression analysis, they reliably explain approximately 36% of the variation in standardised mortality between hospital trusts. Three factors are consistently statistically significant: the number of doctors per hospital bed, bed occupancy, and the percentage of patients who are placed in a bed within four hours after a decision to admit them. Of these, the number of doctors per bed had the strongest effect. Linear regression assumption testing and a robustness analysis indicate the observations have internal validity. However, our empirical strategy cannot determine causality and our findings should not be interpreted as established causal relationships. This study provides hypothesis-generating evidence of significant relationships between systems-based factors of healthcare delivery and standardised mortality. These have relevance to clinicians and policymakers alike. While identifying causal relationships between the predictors is left to the future, it establishes an important paradigm for further research., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Gardner, Kristensen. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

The delivery of primary care to homeless individuals with mental health conditions presents unique challenges. To inform healthcare improvement, we studied predictors of favorable primary care experience among homeless persons with mental health conditions treated at sites that varied in degree of homeless-specific service tailoring. This was a multi-site, survey-based comparison of primary care experiences at three mainstream primary care clinics of the Veterans Administration (VA), one homeless-tailored VA clinic, and one tailored non-VA healthcare program. Persons who accessed primary care service two or more times from July 2008 through June 2010 (N = 366) were randomly sampled. Predictor variables included patient and organization characteristics suggested by the patient perception model developed by Sofaer and Firminger (2005), with an emphasis on mental health. The primary care experience was assessed with the Primary Care Quality-Homeless (PCQ-H) questionnaire, a validated survey instrument. Multiple regression identified predictors of positive experiences (i.e. higher PCQ-H total score). Significant predictors of a positive experience included a site offering tailored service design, perceived choice among providers, and currently domiciled status. There was an interaction effect between site and severe psychiatric symptoms. For persons with severe psychiatric symptoms, a homeless-tailored service design was significantly associated with a more favorable primary care experience. For persons without severe psychiatric symptoms, this difference was not significant. This study supports the importance of tailored healthcare delivery designed for homeless persons needs, with such services potentially holding special relevance for persons with mental health conditions. To improve patient experience among the homeless, organizations may want to deliver services that are tailored to homelessness and offer a choice of providers.

The delivery of primary care to homeless individuals with mental health conditions presents unique challenges. To inform healthcare improvement, we studied predictors of favorable primary care experience among homeless persons with mental health conditions treated at sites that varied in degree of homeless-specific service tailoring. This was a multi-site, survey-based comparison of primary care experiences at three mainstream primary care clinics of the Veterans Administration (VA), one homeless-tailored VA clinic, and one tailored non-VA healthcare program. Persons who accessed primary care service two or more times from July 2008 through June 2010 (N = 366) were randomly sampled. Predictor variables included patient and organization characteristics suggested by the patient perception model developed by Sofaer and Firminger (2005), with an emphasis on mental health. The primary care experience was assessed with the Primary Care Quality-Homeless (PCQ-H) questionnaire, a validated survey instrument. Multiple regression identified predictors of positive experiences (i.e. higher PCQ-H total score). Significant predictors of a positive experience included a site offering tailored service design, perceived choice among providers, and currently domiciled status. There was an interaction effect between site and severe psychiatric symptoms. For persons with severe psychiatric symptoms, a homeless-tailored service design was significantly associated with a more favorable primary care experience. For persons without severe psychiatric symptoms, this difference was not significant. This study supports the importance of tailored healthcare delivery designed for homeless persons' needs, with such services potentially holding special relevance for persons with mental health conditions. To improve patient experience among the homeless, organizations may want to deliver services that are tailored to homelessness and offer a choice of providers.

BackgroundEvidence favoring earlier HIV ART initiation at high CD4+ T-cell counts (CD4>350/uL) has grown, and guidelines now recommend earlier HIV treatment. However, the cost of providing ART to individuals with CD4>350 in Sub-Saharan Africa has not been well estimated. This remains a major barrier to optimal global cost projections for accelerating the scale-up of ART. Our objective was to compute costs of ART delivery to high CD4+count individuals in a typical rural Ugandan health center-based HIV clinic, and use these data to construct scenarios of efficient ART scale-up.MethodsWithin a clinical study evaluating streamlined ART delivery to 197 individuals with CD4+ cell counts >350 cells/uL (EARLI Study: NCT01479634) in Mbarara, Uganda, we performed a micro-costing analysis of administrative records, ART prices, and time-and-motion analysis of staff work patterns. We computed observed per-person-per-year (ppy) costs, and constructed models estimating costs under several increasingly efficient ART scale-up scenarios using local salaries, lowest drug prices, optimized patient loads, and inclusion of viral load (VL) testing.FindingsAmong 197 individuals enrolled in the EARLI Study, median pre-ART CD4+ cell count was 569/uL (IQR 451-716). Observed ART delivery cost was $628 ppy at steady state. Models using local salaries and only core laboratory tests estimated costs of $529/$445 ppy (+/-VL testing, respectively). Models with lower salaries, lowest ART prices, and optimized healthcare worker schedules reduced costs by $100-200 ppy. Costs in a maximally efficient scale-up model were $320/$236 ppy (+/- VL testing). This included $39 for personnel, $106 for ART, $130/$46 for laboratory tests, and $46 for administrative/other costs. A key limitation of this study is its derivation and extrapolation of costs from one large rural treatment program of high CD4+ count individuals.ConclusionsIn a Ugandan HIV clinic, ART delivery costs--including VL testing--for individuals with CD4>350 were similar to estimates from high-efficiency programs. In higher efficiency scale-up models, costs were substantially lower. These favorable costs may be achieved because high CD4+ count patients are often asymptomatic, facilitating more efficient streamlined ART delivery. Our work provides a framework for calculating costs of efficient ART scale-up models using accessible data from specific programs and regions.

Background: Surgical services are scarce with persisting inequalities in access across populations and regions globally. As the world's most populous county, India's surgical need is high and delivery rates estimated to be sub-par to meet need. There is a dearth of evidence, particularly sub-regional data, on surgical provisioning which is needed to aid planning., Aim and Method: This mixed-methods study examines the state of surgical care in Northeast India, specifically health care system capacity and barriers to surgical delivery. It involved a facility-based census and semi-structured interviews with surgeons and patients across four states in the region., Results: Abdominal conditions constituted a large portion of the overall surgeries across public and private facilities in the region. Workloads varied among surgical providers across facilities. Task-shifting occurred, involving non-specialist nursing staff assisting doctors with surgical procedures or surgeons taking on anaesthetic tasks. Structural factors dis-incentivised facility-level investment in suitable infrastructure. Facility functionality was on average higher in private providers compared to public providers and private facilities offer a wider range of surgical procedures. Facilities in general had adequate laboratory testing capability, infrastructure and equipment. Public facilities often do not have surgeon available around the clock while both public and private facilities frequently lack adequate blood banking. Patients' care pathways were shaped by facility-level shortages as well as personal preferences influenced by cost and distance to facilities., Discussion and Conclusion: Skewed workloads across facilities and regions indicate uneven surgical delivery, with potentially variable care quality and provider efficiency. The need for a more system-wide and inter-linked approach to referral coordination and human resource management is evident in the results. Existing task-shifting practices, along with incapacities induced by structural factors, signal the directions for possible policy action., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Virk et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)