Health Stewardship Research Articles

Breast cancer screening and early detection programs in Iran: A health policy analysis and recommendations

AbstractScreening and early detection programs for breast cancer (BC) have significantly reduced mortality rates and enhanced survival rates globally. Breast cancer screening programs in low‐ and middle‐income countries like Iran need improvement. This study examines Iran's breast cancer screening and early detection (BCSED) policies, employing the Policy Triangle Model in two phases: a review of 27 documents including various related sources related of policies and strategies, followed by 20 semi‐structured interviews across four distinct levels: policy, regional, clinical, and community levels. Content analysis for documents and MAXQDA2020 software for the second phase were used, and findings integrated. In our analysis of 27 national documents and 20 interviews, we found 10 themes, 19 sub‐themes, and 42 specific codes across four dimensions of the mentioned framework. Main themes in the context dimension covered deficient interactions, deficiency in knowledge management, cultural challenges, and socioeconomic challenges. From the analysis of 27 national documents, we recognized service excellence schemes, personal health encouragement, and service levels. Policy formulation and monitoring and evaluation emerged as central themes for the process dimension, while stakeholder challenges were prominent in the actors' dimension. BCSED programs are multifactorial issues. Proposed strategies to address these issues include the dedicated funds for BC prevention programs, strengthening the Ministry of Health's stewardship role, elevating public awareness, and conducting systematic screening trials in select cities to provide valuable national evidence for future policymaking.

“Just as curry is needed to eat rice, antibiotics are needed to cure fever”—a qualitative study of individual, community and health system-level influences on community antibiotic practices in rural West Bengal, India

ObjectivesTo understand community antibiotic practices and their drivers, comprehensively and in contextually sensitive ways, we explored the individual, community and health system-level factors influencing community antibiotic practices in rural West...

Health Stewardship in Polar Regions: A Gateway to Establish Emergency Medicine in Extreme Environment.

Health Stewardship in Polar Regions: A Gateway to Establish Emergency Medicine in Extreme Environment.

968. The Impact of Film Array Detection of High-risk and Resistant Pathogens on the Time to Optimal Antibiotic Therapy at a Community Health System

Abstract Background The importance of effective antibiotic therapy for the treatment of bloodstream infections has been well described. Rapid diagnostic testing platforms like the BioFire® FilmArray® blood culture identification (BCID) have the potential to decrease time to effective antibiotics when acted on appropriately. The Cone Health stewardship team has collaborated with clinical pharmacists and infectious diseases physicians to define a process to optimize antibiotic therapy. This process involves microbiology calling a pharmacist with newly positive blood cultures, and the pharmacist notifies the attending physician with the results and evidence-based treatment recommendations. We transitioned from BCID to BCID2 in August, 2021. As CTX-M (marker for extended spectrum beta-lactamase production) was not a target on BCID, we were interested in how the addition of this marker could improve care in this subset of patients. Procedure for Positive Blood Culture Workup and Notification Treatment Recommendations for Selected Organisms Methods From August 2021 - March 2022, the times to administration of effective and optimal antibiotics were evaluated in patients with the following BCID2 organism and resistance gene targets identified: S. aureus, P. aeruginosa, CTX-M, KPC, OXA-48 like, IMP, VIM, NDM, and vancomycin resistant enterococci. An effective antibiotic was defined as an antibiotic with in vitro activity to the organism, and an optimal antibiotic was defined as the preferred agent based on institutional guidelines. For CTX-M isolates, we compared effective and optimal times to a historical control of ceftriaxone resistant enterobacterales and analyzed by student’s t-test. Results The combined mean time from BCID2 to administration of effective antibiotics = 1.2 hours (range 0-7.9 hours) and to optimal therapy =7.6 hours (range 0 – 113.8 hours). Prior to the BCID2 transition, patients found to be growing ceftriaxone resistant enterobacterales had an average time to optimal antibiotic administration of 17.7 hours, which improved to 2.8 hours after BCID2 implementation (p=0.0041). Time to Effective and Optimal Antibiotics after implementation of BCID2 (August 2021 – March 2022) Time to Effective and Optimal Antibiotics for Ceftriaxone Resistant Enterobacterales Prior to BCID2 Implementation (January 2021 - July 2021) Conclusion BioFire® FilmArray® coupled with antibiotic stewardship team support can help optimize time to effective and optimal antibiotic therapy in bloodstream infection. The addition of the CTX-M target to BCID2 was a helpful addition to the panel which allowed for decreased time to optimal antibiotic therapy. Disclosures All Authors: No reported disclosures.

Contributions of the New Framework for Essential Public Health Functions to Addressing the COVID-19 Pandemic.

This article uses a health stewardship perspective to interpret the strengths of and challenges to national health authorities' capacities to respond to the COVID-19 pandemic through the renewed essential public health functions (EPHF) framework. Based on a literature review, this article argues that the institutional capacities required by countries to respond to the COVID-19 pandemic in the Americas included all 4 stages of the new EPHF policy cycle: assessment, policy development, allocation of resources, and access. While health authorities provided these key functions (e.g., data analysis, intersectoral policy dialogues, allocation of additional funds), the interventions implemented depended on each country's own institutional structures. Health authorities faced significant challenges including fragmentation and the lack of institutional and personnel capacities, thus compromising the delivery of an effective and equitable response. In addition, the response to the pandemic has been uneven because of weaknesses in central leadership and coordination capacity, the politicization of the response, and differences in the capacity to respond at subnational levels. Such challenges reflect structural weaknesses that existed before the onset of the pandemic, as well as the low prioritization of public health in agendas for health systems strengthening. A future agenda should prioritize improving structural elements while strengthening the stewardship capacities of health authorities and developing institutional structures that guarantee access to and universal coverage of health services. (Am J Public Health. 2022;112(S6):S615-S620. https://doi.org/10.2105/AJPH.2022.306750).

Ecosystem health, ecosystem services, and the well-being of humans and the rest of nature.

An ecosystem is healthy if it is active, maintains its organization and autonomy over time, and is resilient to stress. Healthy ecosystems provide human well-being via ecosystem services, which are produced in interaction with human, social, and built capital. These services are affected by different ecosystem stewardship schemes. Therefore, society should be aiming for ecosystem health stewardship at all levels to maintain and improve ecosystem services. We review the relationship between ecosystem health and ecosystem services, based on a logic chain framework starting with (1) a development or conservation policy, (2) a management decision or origin of the driver of change, (3) the driver of change itself, (4) the change in ecosystem health, (5) the change in the provision of ecosystem services, and (6) the change in their value to humans. We review two case studies to demonstrate the application of this framework. We analyzed 6,131 records from the Ecosystem Services Valuation Database (ESVD) and found that in approximately 58% of the records data on ecosystem health were lacking. Finally, we describe how the United Nations' System of Environmental-Economic Accounting (SEEA) incorporates ecosystem health as part of efforts to account for natural capital appreciation or depreciation at the national level. We also provide recommendations for improving this system.

Does an Antibiotic Stewardship Applied in a Pig Farm Lead to Low ESBL Prevalence?

Background. The aim of the present study was to prospectively evaluate the prevalence of intestinal carriage of colistin-resistant and extended-spectrum β-lactamase (ESBL)-producing Enterobacterales among pigs from a Swiss farm attending an animal health and antibiotic stewardship program and to determine the associated mechanisms of resistance. Materials/Methods. Eighty-one fecal samples were recovered and screened for either β-lactam-resistant, colistin-resistant, or aminoglycoside-resistant Enterobacterales, using respective screening media. All recovered isolates were tested for antimicrobial susceptibility and their clonal relationship (PFGE and MLST). Plasmid typing was performed by plasmid-based replicon typing (PBRT). Resistance genes were searched by PCR and sequencing. Results. A total of 38 ESBL-producing Escherichia coli and a single ESBL-producing Enterobacter cloacae were recovered from 81 pigs, corresponding to a prevalence of 50%, no other β-lactamase producer being identified. Among the 38 ESBL-producing E. coli, all belonged to sequence type (ST) ST10, except two ST34 and ST744 isolates. Among the ST10-blaCTX-M-1 isolates, three subclones (n = 22, n = 13, and n = 1, respectively) were identified according to the PFGE analysis. The most commonly identified IncI1 plasmid harboring the blaCTX-M-1 gene was 143 kb in size and coharbored other resistance genes. Only three colistin-resistant Enterobacterales isolates were recovered, namely two Klebsiella pneumoniae isolates and a single E. cloacae isolate. Screening for the plasmid-borne mcr-1 to mcr-9 genes in these three isolates gave negative results. The two K. pneumoniae isolates were clonally related, belonged to ST76, and harbored a truncated mgrB chromosomal gene being the source of colistin resistance. Conclusion. A high prevalence of fecal carriage of ESBL-producing E. coli was found, being mainly caused by the spread of a clonal lineage within the farm. By contrast, a low prevalence of colistin-resistant Enterobacterales was found.

Water Stewardship, Health Stewardship.

During the COVID-19 pandemic, masking and hand hygiene are key to individual and public health. Yet many people do not have access to clean water. This painting reiterates the importance of water for health and reminds us to be grateful stewards of this precious natural resource.

23. Regional Variation in Outpatient Antibiotic Prescribing in a Commercially-insured Population, United States, 2017

BackgroundStudies have shown that the Southern United States has higher rates of outpatient antibiotic prescribing compared to other regions in the country, but reasons for this variation are unclear. We aimed to determine whether the regional variability in outpatient antibiotic prescribing for respiratory diagnoses can be explained by differences in patient age, care setting, comorbidities, and diagnosis in a commercially-insured population.MethodsWe analyzed the 2017 IBM® MarketScan® Commercial Database of commercially-insured individuals aged < 65 years. We included visits with acute respiratory tract infection (ARTI) diagnoses from retail clinics, urgent care centers, emergency departments, and physician offices. ARTI diagnoses were categorized as: Tier 1, antibiotics are almost always indicated (pneumonia); Tier 2, antibiotics are sometimes indicated (sinusitis, acute otitis media, pharyngitis); and Tier 3, antibiotics are not indicated (asthma, allergy, bronchitis, bronchiolitis, influenza, nonsuppurative otitis media, viral upper respiratory infections, viral pneumonia). We calculated risk ratios and 95% confidence intervals (CI) stratified by US Census region and ARTI tier using log-binomial models controlling for patient age, comorbidities (Elixhauser and Complex Chronic Conditions for Children), and setting of care, with Tier 3 visits in the West, the strata with the lowest antibiotic prescription rate, as the reference for all strata.ResultsA total of 100,104,860 visits were analyzed. In multivariable modeling, ARTI visits in the South and Midwest were highly associated with receiving an antibiotic for Tier 2 conditions vs. patients in other regions (Figure 1).Figure 1. Multivariable model comparing risk of receiving an antibiotic for an ARTI by region and diagnostic tier in urgent care, retail health, emergency department, and office visits, MarketScan® 2017, United States ConclusionRegional variability in outpatient antibiotic prescribing for Tier 2 and 3 ARTIs remained even after controlling for patient age, comorbidities, and setting of care. It is likely that this variability is in part due to non-clinical factors such as regional differences in clinicians’ prescribing habits and patient expectations. Targeted and enhanced public health stewardship interventions are needed to address cultural factors that affect antibiotic prescribing in outpatient settings.Disclosures All Authors: No reported disclosures

Development of health-based environmental screening levels for insensitive munitions constituents

Dinitroanisole (DNAN), 3-nitro-1,2,4-triazol-5-one (NTO), and nitroguanidine (NQ) are constituents of insensitive munitions being developed to minimize the acute hazards associated with non-intentional detonation of warheads. Although a reference dose (RfD) has been established for NQ and occupational exposure levels have been developed for all three compounds, current state-of-the science methods were not used. Here we present the latest toxicity data and interpretations for NTO, DNAN, and NQ and use Bayesian Benchmark Dose modeling and a Bayesian approach to applying uncertainty factors to derive tolerable daily intake (TDI) values. A TDI of 0.02 mg/kg-d was calculated for DNAN based on extramedullary hematopoiesis in female rats. A TDI of 2.4 mg/kg-d was derived for NTO based on testicular toxicity in male rats. A TDI of 4.0 mg/kg-d was derived for NQ based on increased fetal resorptions in rabbits. These TDIs are generally an order of magnitude higher than previously developed reference values. These values can be used to inform public health, occupational safety, and product acquisition and stewardship decisions. Drinking water, soil, and tap water screening levels were derived for residential and worker exposure scenarios to help inform risk assessment decisions.

Investigation of Health Socialization Status in Iran: A Qualitative Study in 2020

Background: There are significant differences in the health status of different social groups, despite governments' commitment to improving health indicators, which can be avoided by intervening appropriately. In this regard, it can be mentioned that the formation of the social deputy in the Ministry of Health of Iran in 2016, which was dissolved in 1998, and the socialization of health were ignored. Due to the ambiguity in the new process of socialization of health, this study aimed to investigate the status of health socialization in the current structure of the country. Method: The present study as a qualitative study carried out through documentation analysis and two in-depth semi-structured interviews with social deputies of two medical universities of Iran. Data were analyzed using the contractual content analysis method. Two in-depth semi-structured interviews were conducted with the social deputies of the universities of Tehran and Ilam, who were selected using convenience sampling to complete the findings. Result: According to the results of content analysis and 23 extracted codes, the socialization of health in Iran is debatable in two main areas, namely strategies and pillars of socializing health which consisted of three and five sub-themes, respectively. At present, the structure and pillars of socializing health and coordination among these pillars are vague and uncertain due to the distribution of responsibilities of the social deputy in other departments of the Ministry of Health and universities. Conclusion: For achieving equity in the socialization of health goals, it is better to clarify the socialization of health stewardship, strategies, and policies in the whole country concerning social issues and dimensions of the health system.

4115 Fostering a learning environment to train and support versatile scientists who integrate science into real world operations of complex, dynamic health and public health systems

OBJECTIVES/GOALS: The UCLA Clinical and Translational Science Institute’s Population Health Program is creating versatile scientists who can solve population health problems. This means building learning capability in health care and public health agencies, and fostering a cross-sector, outcomes-based, regional ecosystem for implementation and improvement. METHODS/STUDY POPULATION: A synthesis of achievements and lessons learned reveals the Program’s trajectory. It maps progress in science leading to sustainable interventions for target populations. PHP goals are predicated on networked team science, rather than disorganized assortment of individual studies and interventions, and emphasize design, modeling and iteration. Evolving metrics include network analysis to document collaborative impact; extent of integrating real-world application into systems science and learning system curriculum; legislative and institutional policies developed and adopted; evidence of system orientation, cross-sector focus, and implementation research in scientists’ portfolios; and demonstration of population health impact. Barriers offer the opportunity for iteration and improvement. RESULTS/ANTICIPATED RESULTS: The PHP has progressed in its envisioned shared university-public health stewardship of translation and transformation. Milestones included galvanizing activities such as annual regional dissemination, implementation, and improvement (DII) symposia and Public Health Science Summits; pre- and post-doctoral experiential learning of system science and learning system methods based in Los Angeles County Health Agency initiatives; development of a regional CTSA network for implementation science training; strengthened public health policy practice (e.g., establishing a new Office of Youth Diversion and Development); learning healthcare system capability; and prototypes of population learning systems focused on hypertension, food insecurity, tobacco/vaping, and complex care management. DISCUSSION/SIGNIFICANCE OF IMPACT: PHP is committed to advancing science for population health. Prototypes were an essential initial phase. New areas include use of methodological advances (e.g., artificial intelligence, rapid assessments) in health and public health systems; an academic home for full-time, population-focused clinicians; and social policy innovations.

Navigating the Ethics of COVID-19 in Otolaryngology.

The COVID-19 pandemic has dramatically altered how otolaryngologists contemplate and assume their roles in health care delivery. The ethical implications of this pandemic upon our practice are formidable and distinct from other surgical fields. The salient ethical issues of public health stewardship and safety, distributive justice, and nonabandonment are distilled for the practicing otolaryngologist.

Attitude of clinicians towards hospital-based antimicrobial stewardship programs: a multicenter cross-sectional study from Punjab, Pakistan

ABSTRACTBackground: Antimicrobial resistance (AMR) is a major threat to global health and antimicrobial stewardship programs (ASPs) are useful to limit the momentum of AMR. This study was intended to determine the attitudes of clinicians about AMR, ASP strategies, and their readiness to participate in ASPs.Methods: A cross-sectional survey was carried out among clinicians working in teaching hospitals of Punjab between August and November 2018. A multistage sampling method was used. Descriptive statistics and Kruskal-Wallis tests were employed for data analysis.Results: A response rate of 77.9% (670 ⁄ 859) was achieved. Most of the physicians (n = 302, 71.7%) compared to surgeons (n = 134, 70.9%) and anesthetists (n = 25, 41.7%) considered AMR as a serious health problem in Pakistani hospitals (p < 0.001). Clinicians were agreed that hospital audit and feedback (n = 434, 64.8%), restriction of certain antibiotics (n = 424, 63.3%), readily accessible microbiological data (n = 453, 67.6%), and regular educational sessions (n = 496, 74.0%) are imperative approaches to implement ASPs. Median ASP and AMR scores were significantly associated with age, experience, and types of clinicians (p < 0.05).Conclusions: Despite poor previous knowledge of ASPs, all clinicians showed a positive attitude towards hospital ASPs. Several approaches suggested by clinicians will be helpful to implement hospital ASPs in Pakistan.

Stewardship and health systems strengthening: An overview

SummaryThe World Health Organization (WHO) introduced the concept of stewardship to clarify the practical components of governance in the health sector. For the WHO, stewardship concentrated on how government actors take responsibility for the health system and the wellbeing of the population, fulfill health system functions, assure equity, and coordinate interaction with government and society. This article overviews the contents of this special issue, which offers examples of how health stewards in a variety of countries have addressed issues of health security, primary care expansion, family planning, and quality of care. The contributors' articles draw lessons for policy, programs, and management useful for practitioners and scholars. Our overview identifies several themes emerging from the articles: the foundational role of legal frameworks for effective stewardship, the importance of institutional arrangements as enablers, the influence of regional and global entities on national stewardship, the connection between credible decision‐making structures and stewardship, and pathways to sustainable financing and domestic resource mobilization. The discussion concludes with highlighting several gaps in knowledge and practice related to health stewardship.

What Does It Take to Be an Effective National Steward of Digital Health Integration for Health Systems Strengthening in Low- and Middle-Income Countries?

Digital innovations have evolved over the last 15 years to support health activities, and their introduction in low- and middle-income countries has shown the potential to catalyze gains in health systems and service delivery. Despite widespread efforts to roll out these technologies, standardized approaches for formalizing national stewardship responsibilities and ensuring that digital health is a routine, mature, sustainable, and country-owned component of the health system are lacking. In this paper, we define digital health stewardship, with a focus on the ministry of health's role; describe practices undertaken to date; and identify gaps where increased attention could improve sustainability, impact, and local ownership. We conducted a purposeful review of peer-reviewed and gray literature. Of the 404 identified resources from the peer-reviewed literature, 12 met all of the inclusion criteria. After searching various online gray literature repositories, we identified 6 sources based on their quality, source, and relevance. Selected resources were abstracted for relevance to our stewardship themes and synthesized. Findings are presented in 4 broad thematic areas: strategic direction, policies and procedures, roles and responsibilities, and health service delivery implications. Evidence related to strategic direction offers guidance on the main responsibilities under digital health stewardship, including regulations and incentives to promote compliance with standards, mechanisms for oversight, and structures to support evidence-based decisions, and the potential institutional structures and goals that could be used to achieve them. A number of examples of high-level policies and implementation-oriented procedures, such as from the European Commission and the World Health Organization, demonstrate how to operationalize the strategic direction. Available evidence for the remaining themes was sparse, drawing attention to key areas for future work. Despite the importance of country-owned stewardship of digital health, the guidance available is limited and aspirational. Concrete recommendations, including how to adapt existing innovations to the local context, are needed. In particular, the role of external partners needs to be oriented toward building and supporting country capacity to achieve digital health stewardship's potential to support health systems into the future.

Health stewardship: a concept for best health outcomes.

The concept of health stewardship and responsibility for self, marks a shift from adopting a paternalistic approach to care, with decision-making the main remit of healthcare practitioners, towards encouraging and empowering individuals to take increasing responsibility for their healthcare and outcomes. The main aim of nursing is to achieve optimal health outcomes for every patient. Exploring health stewardship as a path to wellness will assist healthcare practitioners to guide patients living with a chronic disease to be as healthy as possible.

The Financial Statement Fraud Risk

The financial statement fraud (FSF) is known as accounting fraud, management fraud, or fraudulent financial reporting (FFR). It takes place when the financial statements (reporting) contains an intentional misrepresentation or omission of material facts (amount, disclosure, or evidence) to deceive the users (Association of Certified Fraud Examiners [ACFE], 2016; Goel & Gangolly, 2012). The financial statements (FS) are necessary to evaluate a company’s performance, financial health, and management stewardship (Eierle & Schultze, 2013). It provides users with useful financial information to make efficient resources allocation and make informed economic decisions (Konigsgruber, 2012). Evidence shows that accounting frauds are still going on by companies, and these frauds misrepresent their financial statements (Bui & Amaria, 2014; Young & Peng, 2013). The perpetration of accounting fraud is still prevalent and costly to the business world (Hays, 2014). The FSF has a significant monetary impact on companies compared to the other categories of frauds (Roxas, 2011). It adversely affects a broad range of stakeholders including companies’ shareholders, creditors, auditors, and others (Parker, 2012). The fraud cost is eventually affecting all members of society in the form of higher prices for provided services or goods (Alleyne & Amaria, 2013). A company’s stock price declines when accounting frauds are revealed, and thereby stockholders suffer the losses and consequences of reputation risks and difficulties in raising corporate capital (Wuerges & Borba, 2014). The FSF continues to grow (Kravitz, 2012). The United States (US) corporate financial fraud cases increased by 37% from 526 cases in 2005 to 725 cases in 2011 (Federal Bureau of Investigation [FBI], 2012). Cases of high-profile management frauds (such Enron, and others) have enormously influenced the global economy and the stock markets (Abbasi, Albrecht, Vance, & Hansen, 2012). These instances of FFR question the roles of auditors, regulators, and others; and raise concerns about the credibility of the financial reporting process (Peytcheva & Warren; 2013; Stancic, Dimitrijevic, & Stancic, 2013).

Enhancing the autonomy of Indian nurses.

With additional training and qualification, nurses in several countries are recognised as independent professionals. Evidence from several countries shows that capacitating nurses to practise independently could contribute to better health outcomes. Recently, the idea of nurses practising independently has been gaining momentum in Indian health policy circles as well, and the Ministry of Health and Family Welfare is contemplating the introduction of nurse practitioners (NPs) in primary healthcare. We briefly assess the policy environment for the role of NPs in India. We argue for the need to conceptualise health stewardship anew, keeping the nursing profession in mind, within the currently doctor-centred health system in India. We argue that, in the current policy environment, conditions for independent nursing practice or for the introduction of a robust NP in primary healthcare do not yet exist.

Legally invisible: stewardship for Aboriginal and Torres Strait Islander health

ObjectivesThe need to improve access to good health care for Aboriginal and Torres Strait Islander people has been the subject of policy debate for decades, but progress is hampered by complex policy and administrative arrangements and lack of clarity about the responsibilities of governments. This study aimed to identify the current legal basis of those responsibilities and define options available to Australian governments to enact enduring responsibility for Aboriginal health care. MethodsThis study used a framework for public health law research and conducted a mapping study to examine the current legal underpinnings for stewardship and governance for Aboriginal health and health care. More than 200 pieces of health legislation were analysed in the context of the common and statutory law and health policy goals. ResultsVery little specific recognition of the needs of Aboriginal people was found, and nothing that creates responsibility for stewardship and governance. The continuing absence of a legislative framework to address and protect Aboriginal health can be traced back to the founding doctrine of terra nullius (unoccupied land). ConclusionsWe considered the results applying both a human rights perspective and the perspective of therapeutic jurisprudence. We suggest that national law for health stewardship would provide a strong foundation for progress, and should itself be based on recognition of Australia's First Peoples in the Australian Constitution, as is currently proposed.