Fragmented Health System Research Articles

Challenges with pediatric surgical financing and universal health coverage in Guatemala: A qualitative analysis.

The financing of surgical care for children in low- and middle-income countries (LMICs) remains challenging and may restrict adherence to universal health coverage (UHC) frameworks. Our aims were to describe Guatemala's national pediatric surgical financing structure, to identify financing challenges, and to develop recommendations to improve the financing of surgical care for children. We conducted a qualitative study of the financing of surgical care for children in Guatemala's public health system with key informant interviews (n = 20) with experts in the medical, financial, and political health sectors. We used this data to generate recommendations to improve surgical care financing for children. We identified several systemic challenges to the financing of surgical care for children, including passive purchasing structures, complex political contexts, health system fragmentation, widespread use of informal fees for surgical services, and lack of earmarked funding for surgical care. Patient and provider challenges include lack of provider input in non-personnel funding decisions, and patients functioning as both financing agents and beneficiaries in the same financing stream. Key recommendations include reducing health finance system fragmentation through resource pooling, increasing earmarked funding for surgical care with quantifiable outcome measures, engagement with clinical providers in non-personnel budgetary decision-making, and use of innovative financing instruments such as resource pooling. Surgical financing for children in Guatemala requires substantial remodeling to increase access to timely, affordable, and safe surgical care and improve alignment with Guatemala's UHC scheme.

Effective access to health care in Mexico

ObjectivesThis paper assesses the impact of effective access on out-of-pocket health payments and catastrophic health expenditure. Effective access cannot be attained unless both health services and financial risk protection are accessible, affordable, and acceptable. Therefore, it represents a key determinant in the transition from fragmented health systems to universal coverage that many low- and middle-income countries face.MethodsWe use a definition of effective access as the utilization of health insurance when available. We conducted a cross-sectional analysis using the 2018 Mexican National Health Survey (ENSANUT) at the household level. The analysis is performed in two stages. The first stage is a multinomial analysis that captures the factor associated with choosing effective access against the alternative of paying privately. The second stage consists of an impact analysis regarding the decision of not choosing effective access in terms of out-of-pocket (OOP) health payments and catastrophic health expenditures (CHE). The analysis corrects for both the decision to buy insurance and the decision to pay for health care.ResultsWe found that, on average, not choosing effective access increases OOP health payments by around 2300 pesos annually. Medicine payments are the most common factor in this increase. Nevertheless, outpatient and medicines health care are the main drivers of the increase in OOP health payments in all insurance beneficiaries. Not having effective access increases the probability of CHE health expenditures by 2.7 p.p. for the case of Social Security Insurance and 4.0 p.p. for Social Government insurance. Household enrolled in Prospera program for the poor are more likely to choose effective access while having household heads with more education and assets value does the opposite. Diabetes illnesses are associated with a higher probability of effective access.ConclusionImproving effective access is a middle step that cannot be disregarded when seeking universal coverage because OOP health payments and catastrophic outcomes are direct consequences. Public insurance in general, has around 50% effective access which remains a challenge in terms of health services utilization and health public policy design, calling for the need of better coordination across insurance types and pooling mechanisms to increase sustainability of needed health services.

Protracted armed conflict and maternal health: a scoping review of literature and a retrospective analysis of primary data from northwest Syria

IntroductionSyria’s protracted conflict has devastated the health system reversing progress made on maternal health preconflict. Our aim is to understand the state of maternal health in Syria focused on underage...

University of Michigan First to Test APA Model for Assessing Psychiatric Bed Needs

University of Michigan First to Test APA Model for Assessing Psychiatric Bed Needs

Developing, Implementing, and Evaluating an Artificial Intelligence-Guided Mental Health Resource Navigation Chatbot for Health Care Workers and Their Families During and Following the COVID-19 Pandemic: Protocol for a Cross-sectional Study.

BackgroundApproximately 1 in 3 Canadians will experience an addiction or mental health challenge at some point in their lifetime. Unfortunately, there are multiple barriers to accessing mental health care, including system fragmentation, episodic care, long wait times, and insufficient support for health system navigation. In addition, stigma may further reduce an individual’s likelihood of seeking support. Digital technologies present new and exciting opportunities to bridge significant gaps in mental health care service provision, reduce barriers pertaining to stigma, and improve health outcomes for patients and mental health system integration and efficiency. Chatbots (ie, software systems that use artificial intelligence to carry out conversations with people) may be explored to support those in need of information or access to services and present the opportunity to address gaps in traditional, fragmented, or episodic mental health system structures on demand with personalized attention. The recent COVID-19 pandemic has exacerbated even further the need for mental health support among Canadians and called attention to the inefficiencies of our system. As health care workers and their families are at an even greater risk of mental illness and psychological distress during the COVID-19 pandemic, this technology will be first piloted with the goal of supporting this vulnerable group.ObjectiveThis pilot study seeks to evaluate the effectiveness of the Mental Health Intelligent Information Resource Assistant in supporting health care workers and their families in the Canadian provinces of Alberta and Nova Scotia with the provision of appropriate information on mental health issues, services, and programs based on personalized needs.MethodsThe effectiveness of the technology will be assessed via voluntary follow-up surveys and an analysis of client interactions and engagement with the chatbot. Client satisfaction with the chatbot will also be assessed.ResultsThis project was initiated on April 1, 2021. Ethics approval was granted on August 12, 2021, by the University of Alberta Health Research Board (PRO00109148) and on April 21, 2022, by the Nova Scotia Health Authority Research Ethics Board (1027474). Data collection is anticipated to take place from May 2, 2022, to May 2, 2023. Publication of preliminary results will be sought in spring or summer 2022, with a more comprehensive evaluation completed by spring 2023 following the collection of a larger data set.ConclusionsOur findings can be incorporated into public policy and planning around mental health system navigation by Canadian mental health care providers—from large public health authorities to small community-based, not-for-profit organizations. This may serve to support the development of an additional touch point, or point of entry, for individuals to access the appropriate services or care when they need them, wherever they are.International Registered Report Identifier (IRRID)PRR1-10.2196/33717

Building a Strong Foundation for Public Health Transformation.

Building a Strong Foundation for Public Health Transformation.

Peer Navigators for the Health Needs of People of Color With Serious Mental Illness.

People with serious mental illness die up to 20 years younger than others in the same age group, with people of color showing even earlier death. The social disadvantages experienced by this group-for example, poverty, criminal legal involvement, and immigration-are further determinants of this disparity. Peer health navigators (PHNs) are people with experiences of recovery who may share a racial-ethnic background, history of poverty, experience with criminal legal systems, or immigration status with current patients and who assist in practical and timely tasks that help people engage with fragmented health systems. This column describes the PHN practice, including the putative components that define it.

Analysis of the COVID-19 pandemic: lessons towards a more effective response to public health emergencies

BackgroundThe pandemic of Coronavirus Disease 2019 (COVID-19) is a timely reminder of the nature and impact of Public Health Emergencies of International Concern. As of 12 January 2022, there were over 314 million cases and over 5.5 million deaths notified since the start of the pandemic. The COVID-19 pandemic takes variable shapes and forms, in terms of cases and deaths, in different regions and countries of the world. The objective of this study is to analyse the variable expression of COVID-19 pandemic so that lessons can be learned towards an effective public health emergency response.MethodsWe conducted a mixed-methods study to understand the heterogeneity of cases and deaths due to the COVID-19 pandemic. Correlation analysis and scatter plot were employed for the quantitative data. We used Spearman’s correlation analysis to determine relationship strength between cases and deaths and socio-economic and health systems. We organized qualitative information from the literature and conducted a thematic analysis to recognize patterns of cases and deaths and explain the findings from the quantitative data.ResultsWe have found that regions and countries with high human development index have higher cases and deaths per million population due to COVID-19. This is due to international connectedness and mobility of their population related to trade and tourism, and their vulnerability related to older populations and higher rates of non-communicable diseases. We have also identified that the burden of the pandemic is also variable among high- and middle-income countries due to differences in the governance of the pandemic, fragmentation of health systems, and socio-economic inequities.ConclusionThe COVID-19 pandemic demonstrates that every country remains vulnerable to public health emergencies. The aspiration towards a healthier and safer society requires that countries develop and implement a coherent and context-specific national strategy, improve governance of public health emergencies, build the capacity of their (public) health systems, minimize fragmentation, and tackle upstream structural issues, including socio-economic inequities. This is possible through a primary health care approach, which ensures provision of universal and equitable promotive, preventive and curative services, through whole-of-government and whole-of-society approaches.

Prevalence of asthma indicators among adolescents in the Global Asthma Network Phase I (GAN Phase I) in Syria (2019–2020)

According to the Global Asthma Report 2018 available from ( www.globanasthmanetwoork.org ): 339 millions have asthma, causing one thousand death per day. While Inhaled Corticosteroids and LABA are in the list of Essential Medicines of WHO, they are not available in half of developing countries, where asthma is not included in health programs, non-referral and fragmented health systems. Global Asthma network launched a worldwide survey at country level, on the prevalence of asthma symptoms, severity, risk factors, and management. This comes 15 year after the International Study of Asthma and Allergies in childhood survey (ISAAC). In Syria, we participate with two centers in Lattakia and Damascus. The standar questionnaire of ISAAC was repeated, the question (Do you havewheezing in the chest the last 12 months), was considered as equivalent of current asthma. With new focus on availability of essential medications, on severity and emergency visits to be matched with under treatment. And new focus on indoor air pollution, in Syria we added questions about exposure to chemicals of weapons and psychiatric disorders linked to the war, we wanted to explore their role on asthma prevalence and severity, Adolescents 13–14 years old in schools are asked by an expert to fill in the GAN questionnaire. While current wheeze prevalence in ISAAC III in Syria was 5.1% for 13–14, it is 19% in GAN ten years later, 12% have criteria of severity. Indeed the war brought new pollutants accused by patients to provoke wheezing and breathlessness p = 0,005 (8% have their asthma appearing after the war), and higher exposure to passive smoking p = 0.001. It is of concern to see that doctor diagnosed asthma was only in 7.8%, wich allude to underdiagnosis. Medications: ICS, LABA, thanks to international help are offered for free in hospitals and shelters. Asthma symptoms and severity should be considered for health program in Syria.

Systematic Review On Strengthening Mental Healthcare In A Fragmented Health System Through A Sustainable Financing Framework Within Counties In Kenya

Systematic Review On Strengthening Mental Healthcare In A Fragmented Health System Through A Sustainable Financing Framework Within Counties In Kenya

The health of internally displaced people in Syria: are current systems fit for purpose?

Introduction: Syria has the largest number of internally displaced people (IDPs) globally with 6.7 million forced from their homes since the uprising erupted in 2011. Most face multiple intersecting vulnerabilities with adverse health impacts. We explore the key health concerns among IDPs, how the various health systems in Syria have responded to the dynamic health needs of IDPs and what modalities have been used by humanitarian actors to address these needs. Methods: We undertook a scoping review of academic and grey literature for available evidence regarding the health of IDPs in Syria. We then organised an online workshop in November 2021 with around 30 participants who represent local, regional, and international organisations and who have relevant expertise. The discussion focused on how the health systems in Syria's various territories have responded to the health needs of IDPs, what this means to the structure and dynamics of these health systems and their intended outcomes and responsiveness. Findings: These emphasised the weak evidence base around IDP health in Syria, particularly in certain geographical areas. Workshop participants explored the applicability of the term IDP in the Syrian context given the fragmented health system and its impact on IDPs, the importance of considering co-determinants (beyond forced displacement) on the health of IDPs and taking a transectoral, community led approach to identify and respond to needs. Conclusion: This manuscript presents some of the current issues with regards to IDP health in Syria, however, there remain numerous unknowns, both for the health of IDP as well as non-IDP populations. We hope that it will be the foundation for further discussions on practical steps relating to research, analysis and interventions which can support health system responses for IDPs in Syria.

Critical Analysis of the South African Universal Health Coverage Policy in Relation to the World Health Organization's Universal Health Coverage Matrix

South Africa is a highly unequal country. The most significant contributors of the poverty index are living conditions (47.5%) and health (39.5%). The country has a two-tiered health system, in which the healthcare system consists of the private sector funded by voluntary health insurance (VHI) and the public sector funded by taxes. Over the last two decades, government transfers as a proportion of total health expenditure (THE) increased significantly from 36% in 2000 to 59% in 2019. Health expenditure per capita and as a percentage of GDP has risen steadily over the period. In South Africa, VHI only covers highincome groups within the private sector leaving shortages of human resources in the public sector. In 2011 the Government published the National Health Insurance (NHI) green paper to introduce a healthcare financing system that will ensure that everyone has access to efficient and appropriate healthcare, based on health needs regardless of ability to pay. This was followed by the white paper, published in 2017, and the National Health Insurance Bill (NHIB) in 2019. The NHIB is currently still undergoing the comments process. Methods: This manuscript uses the WHO framework to critically analyse the South African universal health coverage policy, known as the National Health Insurance policy in relation to World Health Organization's (WHO) framework for health financing and Universal Health Coverage. Findings: The National Health Insurance (NHI) Bill is aligned with the WHO’s universal health care financing framework. The Bill aims to transform the fragmented two-tiered health system, the public and private, unified and equitable health system, revenue rising will consist mainly of public funds, which will be pooled into a single source to enable strategic purchase of services. The Fund will define the benefits once implemented. When finally implementeqd, the legislation will enable efficient and equitable healthcare financing; and access relative to need. Conclusion: The study found that the NHI policy is aligned with WHO’s framework on universal coverage and the desirable attributes. When implemented, the NHI policy will enable South Africa to achieve the intermediate objectives and final goals of universal coverage

Challenges of Guaranteeing Access to Medicines in Mexico: Lessons from Recent Changes in Pharmaceuticals Procurement

ABSTRACT During the last two decades, Mexico adopted policies intended to increase the efficiency and effectiveness of medicines procurement in its nationally fragmented health system. In this policy report, we review Mexico’s efforts to guarantee access to medicines during three national administrations (from 2000 to 2018), and then examine major health system changes introduced by the current government (2018–2024), which have created significant setbacks in guaranteeing access to medicines in Mexico. These recent changes are having important consequences in the levels of satisfaction of health care users and citizens, household expenditure on health, and health conditions. We suggest key lessons for Mexico and other countries seeking to improve pharmaceutical procurement as part of guaranteeing access to medicines.

Implementing COVID-19 surveillance through inter-organizational coordination: a qualitative study of three cities in Colombia.

Introducing comprehensive surveillance is recommended as an urgent public health measure to control and mitigate the spread of coronavirus disease 2019 (COVID-19) worldwide. However, its implementation has proven challenging as it requires inter-organizational coordination among multiple healthcare stakeholders. The purpose of this study was to examine the role of soft and hard mechanisms in the implementation of inter-organizational coordination strategies for COVID-19 surveillance within Colombia, drawing on evidence from the cities of Bogotá, Cali and Cartagena. The study used a case study approach to understand the perspectives of local and national authorities, insurance companies and health providers in the implementation of inter-organizational coordination strategies for COVID-19 surveillance. Eighty-one semi-structured interviews were conducted between June and November 2020. The data were analysed by codes and categorized using New NVivo software. The study identified inter-organizational coordination strategies that were implemented to provide COVID-19 surveillance in the three cities. Both soft (e.g. trust and shared purpose) and hard mechanisms (e.g. formal agreements and regulations) acted as mediators for collaboration and helped to address existing structural barriers in the provision of health services. The findings suggest that soft and hard mechanisms contributed to promoting change among healthcare system stakeholders and improved inter-organizational coordination for disease surveillance. The findings contribute to evidence regarding practices to improve coordinated surveillance of disease, including the roles of new forms of financing and contracting between insurers and public and private health service providers, logistics regarding early diagnosis in infectious disease and the provision of health services at the community level regardless of insurance affiliation. Our research provides evidence to improve disease surveillance frameworks in fragmented health systems contributing to public health planning and health system improvement.

Experiences of women with Zika virus (ZIKV) versus the provision of health services in two cities in Colombia: A qualitative study.

In February 2016, the World Health Organization (WHO) declared the epidemic of the ZIKA virus (ZIKV) in Latin America to be a public health emergency. In Colombia, 11,944 pregnant women registered a ZIKV infection during the epidemic. So far, little is known about the experiences of women infected with ZIKV during their pregnancy, especially those relating to the provision of health services during the period of the epidemic. To explore the experiences of pregnant women diagnosed with ZIKV infection about the provision of health services in two Colombian cities, considering the perspective of sexual and reproductive rights. Qualitative study under the grounded theory approach, which uses semi-structured interviews as tools to explore the biographical experience of mothers during their gestation process and ZIKV infection, dividing the interview into two broad categories: before and during pregnancy. Twenty-two women were interviewed, 10 in Cali and 12 in Villavicencio. The average age at the time of pregnancy was 27.6 years. Most women were not planning at the time of pregnancy and the pregnancy was unwanted. Most campaigns focused on mosquito eradication rather than on sexual and reproductive health campaigns. The quality of health care was not sufficient, adequate, or appropriate. Also, the breakdown of the health system to deal with the pandemic was also noted. Some women were treated with disrespect by health professionals. Voluntary termination of pregnancy was inadequately advised, and women lost autonomy regarding decisions about their health. In the health care of ZIKV epidemics, it is necessary to include the gender perspective, more specifically, sexual and reproductive rights. In addition, these epidemics must be addressed through a comprehensive, appropriate, and not fragmented health system, in which sexual and reproductive rights must be mainstreamed in all health promotion and prevention programs.

Barriers and facilitators to the integration of digital technologies in mental health systems: A protocol for a qualitative systematic review.

IntroductionDigital technology has the potential to improve health outcomes and health system performance in fragmented and under-funded mental health systems. Despite this potential, the integration of digital technology tools into mental health systems has been relatively poor. This is a protocol for a synthesis of qualitative evidence that will aim to determine the barriers and facilitators to integrating digital technologies in mental health systems and classify them in contextual domains at individual, organisational and system levels.Methods and analysisThe methodological framework for systematic review of qualitative evidence described in Lockwood et al. will be applied to this review. A draft search strategy was developed in collaboration with an experienced senior health research librarian. A systematic search of Medline, Embase, Scopus, PsycInfo, Web of Science and Google Scholar, as well as hand searching of reference lists and reviews will identify relevant studies for inclusion. Study selection will be carried out independently by two authors, with discrepancies resolved by consensus. The quality of selected studies will be assessed using JBI Critical Appraisal Checklist for Qualitative Research. Data will be charted using JBI QUARI Data Extraction Tool for Qualitative Research. Findings will be defined and classified both deductively in a priori conceptual framework and inductively by a thematic analysis. Results will be reported based on the Enhancing transparency in reporting the synthesis of qualitative research. The level of confidence of the findings will be assessed using GRADE-CERQual.Ethics and disseminationThis study does not require ethics approval. The systematic review will inform policy and practices around improving the integration of digital technologies into mental health care systems.

Community-Based Mental Health Services in Mexico.

This article describes the general characteristics of community-based mental healthcare in Mexico. Data from national surveys, special studies and statistics from the national information system during the period 2001-2017 are used. Available information on health systems, new regulations and the innovations implemented are reviewed, as well as research on psychosocial interventions conducted within the country. Data show a fragmented health system with services for workers and those without social security or private care. This is a treatment system essentially based on tertiary healthcare and not integrated into the general health system, with a significant treatment gap and delay in relation to the first treatment. At the same time, a slow but steady increase in the level of care provided at primary healthcare level and in specialized community services has been observed. This trend has been accompanied by an increase in the number of medical doctors, psychologists and, to a lesser extent, psychiatrists, incorporated into the primary healthcare services. At the same time, no new psychiatric hospitals have been built; there has been a proportional reduction in psychiatric beds but no increase in mental health services or beds allocated to first contact hospitals. Research initiatives have analysed the barriers to reform, and efficient interventions have been developed and tested for the community and for primary healthcare; special interventions are available for the most vulnerable but no formal efforts have been to facilitate their implementation. Evidence is available regarding the implementation of the transition from reliance on tertiary healthcare to reinforced primary care. At the same time, parity, financial protection, quality and continuity of care remain major challenges.

White Paper on Early Critical Care Services in Low Resource Settings.

This White Paper has been formally accepted for support by the International Federation for Emergency Medicine (IFEM) and by the World Federation of Intensive and Critical Care (WFICC), put forth by a multi-specialty group of intensivists and emergency medicine providers from low- and low-middle-income countries (LMICs) and high-income countries (HiCs) with the aim of 1) defining the current state of caring for the critically ill in low-resource settings (LRS) within LMICs and 2) highlighting policy options and recommendations for improving the system-level delivery of early critical care services in LRS.LMICs have a high burden of critical illness and worse patient outcomes than HICs, hence, the focus of this White Paper is on the care of critically ill patients in the early stages of presentation in LMIC settings. In such settings, the provision of early critical care is challenged by a fragmented health system, costs, a health care workforce with limited training, and competing healthcare priorities.Early critical care services are defined as the early interventions that support vital organ function during the initial care provided to the critically ill patient—these interventions can be performed at any point of patient contact and can be delivered across diverse settings in the healthcare system and do not necessitate specialty personnel.Currently, a single “best” care delivery model likely does not exist in LMICs given the heterogeneity in local context; therefore, objective comparisons of quality, efficiency, and cost-effectiveness between varying models are difficult to establish. While limited, there is data to suggest that caring for the critically ill may be cost effective in LMICs, contrary to a widely held belief. Drawing from locally available resources and context, strengthening early critical care services in LRS will require a multi-faceted approach, including three core pillars: education, research, and policy.Education initiatives for physicians, nurses, and allied health staff that focus on protocolized emergency response training can bridge the workforce gap in the short-term; however, each country’s current human resources must be evaluated to decide on the duration of training, who should be trained, and using what curriculum.Understanding the burden of critical Illness, best practices for resuscitation, and appropriate quality metrics for different early critical care services implementation models in LMICs are reliant upon strengthening the regional research capacity, therefore, standard documentation systems should be implemented to allow for registry use and quality improvement.Policy efforts at a local, national and international level to strengthen early critical care services should focus on funding the building blocks of early critical care services systems and promoting the right to access early critical care regardless of the patient’s geographic or financial barriers. Additionally, national and local policies describing ethical dilemmas involving the withdrawal of life-sustaining care should be developed with broad stakeholder representation based on local cultural beliefs as well as the optimization of limited resources.

Cancer control in Latin America and the Caribbean: recent advances and opportunities to move forward.

The increasing burden of cancer represents a substantial problem for Latin America and the Caribbean. Two Lancet Oncology Commissions in 2013 and 2015 highlighted potential interventions that could advance cancer care in the region by overcoming existing challenges. Areas requiring improvement included insufficient investment in cancer control, non-universal health coverage, fragmented health systems, inequitable concentration of cancer services, inadequate registries, delays in diagnosis or treatment initiation, and insufficient palliative services. Progress has been made in key areas but remains uneven across the region. An unforeseen challenge, the COVID-19 pandemic, strained all resources, and its negative effect on cancer control is expected to continue for years. In this Series paper, we summarise progress in several aspects of cancer control since 2015, and identify persistent barriers requiring commitment of additional resources to reduce the cancer burden in Latin America and the Caribbean.

Towards a Program Theory for Family-Focused Practice in Adult Mental Health Care Settings: An International Interview Study With Program Leaders.

Objectives: In several high-income countries, family-focused practice programs have been introduced in adult mental health care settings to identify and support children whose parents live with mental health problems. Whilst their common goal is to reduce the impact of parental mental illness on children, the mechanisms by which they improve outcomes in different systems and settings are less well known. This kind of knowledge can importantly contribute to ensuring that practice programs achieve pre-defined impacts.Methods: The aim of this study was to develop knowledge about relationships between contextual factors, mechanisms and impact that could inform a program theory for developing, implementing, and evaluating family-focused practice. Principles of a realist evaluation approach and complex system thinking were used to conceptualize the design of semi-structured in-depth interviews with individuals who led the implementation of programs. Seventeen individuals from eight countries participated in the study.Results: Interviewees provided rich accounts of the components that programs should include, contextual factors in which they operated, as well as the behavior changes in practitioners that programs needed to achieve. Together with information from the literature, we developed an initial program theory, which illustrates the interconnectedness between changes that need to co-occur in practitioners, parents, and children, many of which related to a more open communication about parental mental health problems. Stigma, risk-focused and fragmented health systems, and a lack of management commitment were the root causes explaining, for example, why conversations about parents' mental illness did not take place, or not in a way that they could help children. Enabling practitioners to focus on parents' strengths was assumed to trigger changes in knowledge, emotions and behaviors in parents that would subsequently benefit children, by reducing feelings of guilt and improving self-esteem.Conclusion: To our knowledge, this is the first research, which synthesizes knowledge about how family-focused practice programs works in a way that it can inform the design, implementation, and evaluation of programs. Stakeholder, who fund, design, implement or evaluate programs should start co-developing and using program theories like the one presented in this paper to strengthen the design and delivery of family-focused practice.