Health System Interventions Research Articles

Integrating international policy standards in the implementation of postnatal care: a rapid review

IntroductionInternational legal and political documents can assist policy-makers and programme managers in countries to create an enabling environment to promote maternal and newborn health. This review aimed to map and...

Integrated health system intervention aimed at reducing type 2 diabetes risk in women after gestational diabetes in South Africa (IINDIAGO): a randomised controlled trial protocol

IntroductionSouth Africa has a high prevalence of gestational diabetes mellitus (GDM; 15%) and many of these women (48%) progress to type 2 diabetes mellitus (T2DM) within 5 years post partum....

Opportunities and challenges on hospital preparedness to handle motorcycle accidents in Busia County, Kenya: an exploratory qualitative study.

motorcycles continue to be a popular mode of transport in Kenya. However, the related injuries cause significant morbidity and mortality and remain to be a major and neglected public health issue. This raised the crucial need for hospital preparedness in managing morbidities and in reducing mortalities. This formed the basis of this paper which aims to document the challenges and opportunities in the healthcare system in handling motorcycle accidents in a Kenyan border town in Busia County. we drew data from an exploratory qualitative study that was carried out in 2021. All six referral hospitals purposively included in the study. The study targeted a total of 25 top level facility managers as key informants on the facility level opportunities and challenges in handling motorcycle accidents. Descriptive data were analyzed using SPSS version 20. the hospitals were not well prepared to handle motorcycle accidents. The major challenges were understaffing in critical care services; inadequate/lack of equipment to handle motorcycle injuries; inadequate/lack of infrastructure i.e. surgical wards, emergency rooms, inadequate space, functional theatre; lack/inadequate supplies; overstretched referral services arising from the hinge burden of motorcycle accidents in the area; inadequate specialized personnel to provide trauma/care services; mishandling of cases at the site of accident; inability of victims to pay related bills; inappropriate identification of victims at the facility; lack/inadequate on-job training. Some opportunities that currently exist include health system interventions which are not limited to employment of more professionals, improvement of infrastructure, provision of equipment and increase of budgetary allocation. the study reveals vast challenges that are faced by hospitals in managing patients. This calls for the government to step in and capitalize on the proposed opportunities by the health managers to be able to manage morbidities and bring down mortalities due to motorcycle accidents.

Redefining global cardiac surgery through an intersectionality lens

Although cardiovascular diseases are the leading cause of morbidity and mortality worldwide, six billion people lack access to safe, timely and affordable cardiac surgical care when needed. The burden of...

Abstract C099: Take CARE: An implementation science initiative to reduce the cervical cancer burden in Appalachia

Abstract Appalachia has a higher burden of cervical cancer than other regions of the United States. Cervical cancer risk factors and causes are largely known, so evidence-based interventions in health systems addressing those factors and causes can improve cervical cancer incidence and mortality rates. Take CARE (Clinical Avenues to Reach Health Equity) is designed to address three factors strongly associated with cervical cancer and is made up of three evidence-based complementary initiatives focused on HPV vaccination, smoking cessation, and cervical cancer screening: I Vaccinate, Break Free, and The HOME Initiative, respectively. The overall goal is to use implementation science designs to provide an integrated approach to reduce cervical cancer risk among patients of 39 health centers from ten participating systems. The project was implemented in two phases: formative and trial. In the formative phase, community profiles were developed to better understand the cancer burden and resources available. Community members and clinic staff were interviewed about barriers to cervical cancer screening and HPV vaccination and norms about screening, vaccination, and tobacco cessation. Findings informed study materials. Clinic champions were identified, and implementation teams were formed to support the champion role. Details were gathered about facility processes, staffing, patient load, and existing cervical cancer-related activities. Waiting room seating, availability of digital displays, number of exam rooms, and locations for promotional materials and staff trainings were documented through environmental scans. The trial phase was introduced as a delayed group implementation design in ten health systems located in Appalachian counties of Kentucky, Ohio, Virginia, and West Virginia from October 2020 to June 2022. Five systems were assigned to an Early Group and five to a Late Group that would receive the intervention 12 months after Early systems. I Vaccinate was first to be implemented, promoting HPV vaccination in 9–45-year-olds. Health systems receive education materials and providers select strategies and set goals to improve vaccination rates. Break Free was introduced six to eight weeks later and identifies eligible smokers who want to quit in the next six months, providing free smoking cessation counseling and medication to patients. Systems received education on the Ask, Advise, Refer model and could select staff to be trained as Tobacco Treatment Specialists. HOME was the final initiative introduced and focuses on improving cervical cancer screening in underscreened female patients via a mail-based HPV self-sampling program. One year after the first initiative launched, health systems were taught to bundle the initiatives as one program, Take CARE. After this, the Early systems entered a sustainability phase for two years. The process will occur similarly for Delayed health systems but with only one year of sustainability. Analyses will focus on changes in HPV vaccination, smoking cessation, and cervical cancer screening over time. Citation Format: Ryan D. Baltic, Roger Anderson, Mark B. Dignan, Amy K. Ferketich, Mira L. Katz, Stephenie Kennedy, Paul L. Reiter, Electra D. Paskett. Take CARE: An implementation science initiative to reduce the cervical cancer burden in Appalachia [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr C099.

Diabetes self-management and social support during the COVID-19 pandemic: Perspectives of older adults living in Barbados.

Diabetes mellitus (diabetes) is a major health concern in Barbados. In 2013, the reported prevalence (18.7%) was double global levels, with diabetes accounting for 10.4% of total deaths in 2016. Barbados has a rapidly aging population and older adults living with diabetes are more at risk of developing complications. Poorly managed diabetes represents a high burden for individuals and society due to direct healthcare costs for treatment, and to indirect costs due to loss of productivity from disability and premature mortality. Good diabetes self-management promotes glycemic control. Self-management is enhanced by social support and challenged by external shocks. This study explored the role of social support in diabetes self-management among older people in Barbados during the COVID-19 pandemic. Qualitative secondary thematic analysis of semi-structured individual telephone interviews with adults aged 65-84 years living with diabetes in Barbados during a partial COVID-19 lockdown period. Sampling was purposive, aided by gatekeepers who provide services to elderly people. Verbatim interview transcripts coded using an inductive method were subjected to thematic analysis by three qualitative researchers using NVIVO software. Four organising themes: "Balance", "Social Capital", "Resilience", and "Adaptations to COVID-19", informed the global theme "Adaptive Diabetes Self-Management Response", which captures resilience mechanisms of older adults who balanced facilitators including self-reliance and religious faith, and barriers such as perceived ageist discrimination in workplace policies designed to reduce COVID-19 exposure. Accordingly, elderly Barbadians living with diabetes were resilient, selectively incorporating available social support mechanisms to maintain self-management and overall well-being during the COVID-19 pandemic. The emergent evidence for resilience among older persons in this setting is important for informing health system interventions to improve quality of life for PLWD. The views of the elderly should be explicitly considered in policies designed to enhance the self-management of chronic health conditions.

Implementation of a health system intervention to reduce time from presentation to surgical intervention for pediatric testicular torsion

Testicular salvage rates for torsion are time-dependent1. Door to detorsion time has been identified as an independent testicular survival factor2. We describe an initiative to reduce door to incision (DTI) time for pediatric testicular torsion. An institutional multidisciplinary quality improvement initiative with a primary outcome of reducing DTI time for pediatric testicular torsion was developed with multidisciplinary stakeholders. Several process and balancing measures were used as secondary outcomes to help interpret and verify the observed change in DTI time. Interventions were implemented in cycles. Initial interventions standardized assessment of suspected torsion by Emergency Medicine utilizing a validated scoring system. A threshold Testicular Workup for Ischemia and Suspected Torsion (TWIST) score led to parallel notification of essential services for rapid assessment and case prioritization3. Subsequently, bedside ultrasound in the Emergency Department was implemented. Progress was tracked in a live dashboard and analyzed with X-mR process control charts and Nelson rules. These tools are used in quality improvement and process control to demonstrate the significance of changes as they are being implemented, prior to when traditional hypothesis testing would be able to do so. We aimed to increase the proportion of cases with DTI times under 4h from 64% to >90% within one year. We observed 22 torsion cases prior to and 62 following initial implementation. The percentage of cases with DTI times under 4h improved from 64% to 95%. At week 29, a shift identified a significant change on the X chart, with reduction in mean DTI time from 221 to 147min. At the same time, a shift on the mR chart identified reduction in patient-to-patient variation. Mean time from arrival to Urology evaluation decreased from 140 to 56min, mean time from arrival to scrotal ultrasound decreased from 70 to 36min, and mean time from scrotal ultrasound to surgical incision decreased from 128 to 80min. These improvements highlight the two key successes of our project: application of the TWIST score and bedside ultrasound for rapid assessment of suspected testicular torsions, and parallel processing of the evaluation and management. Implementation of a protocol for pediatric testicular torsion increased the proportion of cases with DTI time <4h to 95%, decreased mean DTI time, and decreased variation. Our protocol provides a model to improve timeliness of care in treating pediatric testicular torsion.

Patient, Parent, and Provider Perceptions of Barriers to Pediatric Inflammatory Bowel Disease Care.

Children with inflammatory bowel disease (IBD) have a significant life-long burden as a result of disease, impacted by environmental and individual barriers. Successful health system interventions require a comprehensive approach, informed by various stakeholders. The main objective was to identify health system barriers and potential solutions from existing patients, families, and providers via focus groups. Participants for the focus groups were existing English-speaking patients (ages 9-18) with IBD, their caregiver(s), and providers including multiple professions (eg, physician, nurse, pediatrician, social worker, care coordinator, scheduler, and psychologist). Separate focus groups were led by experienced personnel for parents, children, and providers, using a standardized interview guide. Sessions were recorded, transcribed, and verified. Using content analysis, we systematically classified data through coding and identified themes. Focus groups comprised (a) 3 patient groups (n = 20, 50% female, including 2 younger; mean age = 11.4 ± 1.5 years) and 1 older group (mean age = 15.6 ± 1.3 years), (b) 3 parent groups (n = 24, 83% female), and (c) 2 multidisciplinary provider groups (n = 19). Families shared several common concerns with providers (eg, school, care delay, psychosocial, and financial) but varied on specifics. Some barriers may be addressable through family or staff education, improved communication (eg, care delay/ access, transition), or training (eg, labs and diet), while others may require change at an institutional or policy level (eg, insurance). This qualitative analysis identified several barriers to IBD care, some shared, some unique to patients, parents, and providers, highlighting the importance of obtaining multiple stakeholder perspectives when exploring barriers to care.

Public Health Responses to Homelessness During COVID-19 in Ireland: Implications for Health Reform

The intersection between health and homelessness is well documented and has been made more explicit since the onset of the coronavirus disease of 2019 (COVID-19). In the Global North, COVID-19 related public health responses targeting homeless populations have varied across countries, including greater national-level financial investment, temporarily housing those in congregate facilities in ‘self-contained’ accommodation, time-limited eviction moratoriums and dedicated health system interventions across homelessness and addiction services to enable social distancing and self-isolation. Yet questions remain about the immediate and longer-term outcomes of these newly implemented responses and whether they will be sustained. Such considerations are critical and timely in countries such as Ireland, where significant health reform is underway. In this paper, we use Ireland as a case study to explore whether and how public health responses to homelessness during COVID-19 hold important insights for the development of more effective health policy. Drawing on publicly available Irish data, we present a secondary analysis of COVID-19 infection rates amongst homelessness service users as well as trends in emergency accommodation usage between 2020 and 2021. Focusing specifically on public health measures implemented during the pandemic via the health and housing systems, respectively, we discuss how such interventions may have impacted on these homelessness figures in both intended and unexpected ways. We conclude by teasing out and unpacking relevant lessons for health reform.

Understanding Barriers and Facilitators to High-Quality Cancer Care Among Veterans With Lung Cancer: A Qualitative Study.

Veteran populations have higher lung cancer incidence and worse overall survival compared with non-Veteran populations. Although recent clinical advancements have reduced lung cancer death rates, these advances are not routinely received among Veteran populations because of multilevel factors, including Veterans' complex comorbidities, limited health literacy, and other economic and social disadvantages. This study aimed to assess Veterans' perspectives regarding their lung cancer care with a specific focus on identifying modifiable barriers to evidence-based care delivery. We conducted 1:1 semistructured interviews with 24 Veterans diagnosed with lung cancer at the Veterans Affairs Palo Alto Health Care System. All interviews were recorded, transcribed, and analyzed using the constant comparative method of qualitative analysis. Four themes emerged. These included (1) social and economic disadvantages can prevent routine delivery of evidence-based cancer care; (2) fragmented care contributes to worsening patient mental and emotional well-being; (3) lack of health system interventions to address limited health literacy inhibits patient engagement in shared decision making regarding diagnosis, genomic and molecular testing, targeted and other treatments, and end-of-life care; and (4) deep appreciation for care and VA trustworthiness facilitates adherence to cancer care recommendations. This study revealed critical gaps in lung cancer care delivery and the role of institution-engendered trust in overcoming barriers in the VA system. Targeted solutions should address the identified barriers to routine, evidence-based lung cancer care delivery among Veterans.

Critical elements of synthesis questions are incompletely reported: survey of systematic reviews of intervention effects

ObjectivesTo examine the characteristics of population, intervention and outcome groups and the extent to which they were completely reported for each synthesis in a sample of systematic reviews (SRs) of interventions. Study design and settingWe coded groups that were intended (or used) for comparisons in 100 randomly sampled SRs of public health and health systems interventions published in 2018 from the Health Evidence and Health Systems Evidence databases. ResultsAuthors commonly used population, intervention and outcome groups to structure comparisons, but these groups were often incompletely reported. For example, of 41 SRs that identified and/or used intervention groups for comparisons, 29 (71%) identified the groups in their methods description before reporting of the results (e.g., in the Background or Methods), 12 (29%) defined the groups in enough detail to replicate decisions about which included studies were eligible for each synthesis, 6 (15%) provided a rationale, and 24 (59%) stated that the groups would be used for comparisons. Sixteen (39%) SRs used intervention groups in their synthesis without any mention in the methods. Reporting for population, outcome and methodological groups was similarly incomplete. ConclusionComplete reporting of the groups used for synthesis would improve transparency and replicability of reviews, and help ensure that the synthesis is not driven by what is reported in the included studies. Although concerted effort is needed to improve reporting, this should lead to more focused and useful reviews for decision-makers.

The association between temperature and alcohol- and substance-related disorder hospital visits in New York State

BackgroundLimited evidence exists on how temperature increases are associated with hospital visits from alcohol- and substance-related disorders, despite plausible behavioral and physiological pathways.MethodsIn the present study, we implemented a case-crossover design, which controls for seasonal patterns, long-term trends, and non- or slowly-varying confounders, with distributed lag non-linear temperature terms (0–6 days) to estimate associations between daily ZIP Code-level temperature and alcohol- and substance-related disorder hospital visit rates in New York State during 1995–2014. We also examined four substance-related disorder sub-causes (cannabis, cocaine, opioid, sedatives).ResultsHere we show that, for alcohol-related disorders, a daily increase in temperature from the daily minimum (−30.1 °C (−22.2 °F)) to the 75th percentile (18.8 °C (65.8 °F)) across 0–6 lag days is associated with a cumulative 24.6% (95%CI,14.6%–34.6%) increase in hospital visit rates, largely driven by increases on the day of and day before hospital visit, with an association larger outside New York City. For substance-related disorders, we find evidence of a positive association at temperatures from the daily minimum (−30.1 °C (−22.2 °F)) to the 50th percentile (10.4 °C (50.7 °F)) (37.7% (95%CI,27.2%–48.2%), but not at higher temperatures. Findings are consistent across age group, sex, and social vulnerability.ConclusionsOur work highlights how hospital visits from alcohol- and substance-related disorders are currently impacted by elevated temperatures and could be further affected by rising temperatures resulting from climate change. Enhanced social infrastructure and health system interventions could mitigate these impacts.

Medium-to-long term sustainability of a health systems intervention to improve service readiness and quality of non-communicable disease (NCD) patient care and experience at primary care settings in Uganda

BackgroundWith the double burden of rising chronic non-communicable diseases (NCDs) and persistent infectious diseases facing sub-Saharan Africa, integrated health service delivery strategies among resource-poor countries are needed.Our study explored the post-trial sustainability of a health system intervention to improve NCD care, introduced during a cluster randomised trial between 2013 and 2016 in Uganda, focusing on hypertension (HT) and type-2 diabetes mellitus (DM) services.In 2020, 19 of 38 primary care health facilities (HFs) that constituted the trial’s original intervention arm until 2016 and 3 of 6 referral HFs that also received the intervention then, were evaluated on i) their facility performance (FPS) through health worker knowledge, and service availability and readiness (SAR), and ii) the quality-of-patient-care-and-experience (QoCE) received.MethodsCross-sectional data from the original trial (2016) and our study (2020) were compared. FPS included a clinical knowledge test with 222 health workers: 131 (2016) and 91 (2020) and a five-element SAR assessment of all 22 HFs. QoCE assessment was performed among 420 patients: 88 (2016) and 332 (2020). Using a pair-matched approach, FPS and QoCE summary scores were compared. Linear and random effects Tobit regression models were also analysed.ResultsThe mean aggregate facility performance (FPS) in 2020 was lower than in 2016: 70.2 (95%CI = 66.0–74.5) vs. 74.8 (95%CI = 71.3–78.3) respectively, with no significant difference (p = 0.18). Mean scores declined in 4 of 5 SAR elements.Overall FPS was negatively affected by rural or urban HF location relative to peri-urban HFs (p < 0.01). FPS was not independently predicted but patient club functionality showed weak association (p = 0.09).QoCE declined slightly to 8.7 (95%CI = 8.4–91) in 2020 vs 9.5 (95%CI = 9.1–9.9) in 2016 (p = 0.02) while the proportion of patients receiving adequate quality care also declined slightly to 88.2% from 98.5% respectively, with no statistical difference (p = 0.20). Only the parent district weakly predicted QoCE (p = 0.05).ConclusionsFour years after the end of research-related support, overall facility performance had declined as expected because of the interrupted supplies and a decline in regular supervision. However, both service availability and readiness and quality of HT/DM care were surprisingly well preserved.Sustainability of an NCD intervention in similar settings may remain achievable despite the funding instability following a trial’s end but organisational measures to prepare for the post-trial phase should be taken early on in the intervention process.

Outcomes measured in studies assessing health systems interventions for type 1 diabetes management: A scoping review.

Describe the outcomes reported in research on health systems interventions for type 1 diabetes management in comparison to the outcomes proposed by a core outcome set (COS) for this condition, an essential list of outcomes that studies should measure. Systematic search of studies published between 2010 and 2021 reporting health systems interventions directed to improve the management of type 1 diabetes using PubMed, EMBASE and CENTRAL. Information on the outcomes was extracted and classified according to a COS: self-management, level of clinical engagement, perceived control over diabetes, diabetes-related quality of life, diabetes burden, diabetes ketoacidosis, severe hypoglycemia, and glycated hemoglobin (HbA1C). 187 studies were included. Most of the studies included either children (n = 82/187) or adults (n = 82/187) living with type 1 diabetes. The most common outcome measured was HbA1C (n = 149/187), followed by self-management (n = 105/187). While the least measured ones were diabetes ketoacidosis (n = 15/187), and clinical engagement (n = 0/187). None of the studies measured all the outcomes recommended in the COS. Additionally, different tools were found to be used in measuring the same outcome. This study provides a description of what researchers are measuring when assessing health systems interventions to improve type 1 diabetes management. In contrast to a COS, it was found that there is a predominance of clinical-based outcomes over patient-reported outcome measures.

Incidence and age at diagnosis of 31 long-term conditions and multimorbidity by sex and social class in a Scottish population

A good understanding of age, when individuals develop individual conditions and subsequently become multimorbid, would provide evidence to support better prevention, detection, and management of multiple long-term conditions. The study aimed to assess the age at onset, incidence, and prevalence of 31 long-term conditions and multimorbidity in Fife and Tayside, Scotland by sex and socioeconomic status.&#x0D; We linked routinely collected health records of 431,772 patients aged 25 years or higher on January 1st, 2000 till December 31st, 2018 from several database. Age of first report of the 31 Elixhauser long-term conditions was assessed.&#x0D; Median age at the onset of conditions within the population ranged from 39 years for AIDS/HIV to 73 years for fluid and electrolyte disorders and 75 years for renal failure. This was mostly delayed among the least deprived than most deprived people, up to 14 years for psychoses and AIDS/HIV. People with the highest deprivation in both sexes had earlier onset of all conditions except for blood loss anaemia where most deprived males had three years delay. Median age at the onset of multimorbidity and complex multimorbidity was 67 years (68 for females vs 66 for males; 68 for most deprived vs 73 for least deprived) and 71 years (73 for females vs 70 for males; 73 for most deprived vs 78 for least deprived) respectively. The yearly incidence of both multimorbidity and complex multimorbidity rose steadily from 1.6% and 0.2% in 2000, peaked in 2015 (3.2% vs 1.4%), declined to 2.9% and 1.3% respectively in 2018 while the prevalence grew from 1.6% and 0.2% to 27.2% and 10.1% over the same period.&#x0D; A number of conditions had earlier onset while others were delayed. The onset of conditions is generally about five years earlier among most deprived people than the least deprived just as multimorbidity and complex multimorbidity is higher and earlier among the most deprived. This information could help drive health system policy, management, intervention, and allocation of resources.

Sustainability capacity and health worker normalisation of a successful non-communicable disease (NCD) health systems intervention within primary care settings in Uganda: a quantitative approach to a qualitative question

BackgroundInterventions for non-communicable diseases are increasingly implemented and evaluated in sub-Saharan Africa, but little is known about their medium- to long-term sustainability beyond the end of research funding. A cluster randomised trial conducted between 2013 and 2016 in Uganda and Tanzania showed that an intervention package to improve hypertension (HT) and type-2 diabetes mellitus (DM) care was highly effective in increasing service readiness and quality of care. The present study assesses the sustainability of the intervention 4 years after the trial in Uganda.MethodsThe study was conducted in 2020 in 22 primary care health facilities (HFs) (3 referrals and 19 lower-level units) that had received the intervention package until trial end (2016), to assess their current capacity and practice to sustain ongoing intervention activities for HT and DM care. Through a cross-sectional survey, 4 pre-defined domains (i.e., cognitive participation, coherence, collective action, and reflexive monitoring) were examined with regard to health worker (HW) normalization and 8 pre-defined domains for intervention sustainability (i.e., organisational capacity, local environment, funding stability, partnerships, communication, evaluation, adaptation, and strategic planning), using the normalisation tool and the program sustainability tool (PSAT). Summary scores were assessed by domains and facility level.ResultsOverall normalization strength was adequate at 4.0 (IQR: 3.8, 4.2) of a possible 5 with no evidence of association with HF level (p = 0.40); cognitive participation (buy-in) and reflexive monitoring (appraisal) were strongest at > 4 across all HF levels. All HF levels were weak (< 4) on collective action (teamwork) and coherence (sense-making). Only collective action differed by level (p < 0.002). Overall intervention sustainability was suboptimal at 3.1 [IQR: 1.9, 4.1] of a possible 7 with weak scores on funding stability (2.0), supportive partnerships (2.2), and strategic planning (2.6). Domain differences by HF level were significant for environmental support (p = 0.02) and capacity in organisation (p = 0.01). Adequate strength at a cut-off mean of ≥5 did not differ by HF level for any domain.ConclusionsFour years after their introduction, practice-dependent intervention elements e.g., local organisational context, HW knowledge or dedication were sustained, but external elements e.g., new funding support or attracting new partners to sustain intervention efforts were not. Whenever new interventions are introduced into an existing health service, their long-term sustainability including the required financial support should be ensured. The quality of services should be upheld by providing routine in-service training with dedicated support supervision.

Use of hospital services by patients with chronic conditions in sub-Saharan Africa: a systematic review and meta-analysis.

To estimate the prevalence of individual chronic conditions and multimorbidity among adults admitted to hospital in countries in sub-Saharan Africa. We systematically searched MEDLINE®, Embase®, Global Index Medicus, Global Health and SciELO for publications reporting on patient cohorts recruited between 1 January 2010 and 12 May 2023. We included articles reporting prevalence of pre-specified chronic diseases within unselected acute care services (emergency departments or medical inpatient settings). No language restrictions were applied. We generated prevalence estimates using random-effects meta-analysis alongside 95% confidence intervals, 95% prediction intervals and I2 statistics for heterogeneity. To explore associations with age, sex, country-level income status, geographical region and risk of bias, we conducted pre-specified meta-regression, sub-group and sensitivity analyses. Of 6976 identified studies, 61 met the inclusion criteria, comprising data from 20 countries and 376 676 people. None directly reported multimorbidity, but instead reported prevalence for individual conditions. Among medical admissions, the highest prevalence was human immunodeficiency virus infection (36.4%; 95% CI: 31.3-41.8); hypertension (24.4%; 95% CI: 16.7-34.2); diabetes (11.9%; 95% CI: 9.9-14.3); heart failure (8.2%; 95% CI: 5.6-11.9); chronic kidney disease (7.7%; 95% CI: 3.9-14.7); and stroke (6.8%; 95% CI: 4.7-9.6). Among patients seeking hospital care in sub-Saharan Africa, multimorbidity remains poorly described despite high burdens of individual chronic diseases. Prospective public health studies of multimorbidity burden are needed to generate integrated and context-specific health system interventions that act to maximize patient survival and well-being.

Equity in virtual care: A mixed methods study of perspectives from physicians.

Virtual care expanded rapidly during the COVID-19 pandemic, and how this shift affected healthcare disparities among subgroups of patients is of concern. Racial and ethnic minorities, older adults, individuals with less education, and lower-income households have lower rates of home broadband, smartphone ownership, and patient portal adoption, which may directly affect access to virtual care. Because primary care is a major access point to healthcare, perspectives of primary care providers are critical to inform the implementation of equitable virtual care. The aim of this mixed methods study was to explore primary care physician experiences and perceptions of barriers and facilitators to equitable virtual care. We used an explanatory sequential mixed methods design, which consists of first collecting and analyzing quantitative survey data, then using those results to inform a qualitative follow-up phase to explain and expand on results. Primary care physicians in a family medicine department at an academic medical center responded to surveys (n = 38) and participated in interviews (n = 16). Participants completed a survey concerning frequency and preferences about video visits, pros and cons of video visits, communication aspects, and sufficiency of the technology. A purposeful sample of participants completed semi-structured interviews about their virtual care experiences with a focus on equity for subpopulations. The results indicated that physicians have observed equity issues for unique patient populations. The results add to the understanding of nuanced ways in which virtual care can increase and decrease healthcare access for unique populations. Patients with limited English proficiency were particularly affected by inequity in virtual care access. Additional research and interventions are needed to improve portal access for those with limited English proficiency. Improvements should focus on health system interventions that expand access without requiring increased patient burden.

Language-Concordant Care: a Qualitative Study Examining Implementation of Physician Non-English Language Proficiency Assessment

BackgroundLanguage concordance can increase access to care for patients with language barriers and improve patient health outcomes. However, systematically assessing and tracking physician non-English language skills remains uncommon in most health systems. This is a missed opportunity for health systems to maximize language-concordant care.ObjectiveTo determine barriers and facilitators to participation in non-English language proficiency assessment among primary care physicians.DesignQualitative, semi-structured interviews.ParticipantsEleven fully and partially bilingual primary care physicians from a large academic health system with a language certification program (using a clinician oral proficiency interview).ApproachInterviews aimed to identify barriers and facilitators to participation in non-English language assessment. Two researchers independently and iteratively coded transcripts using a thematic analysis approach with constant comparison to identify themes.Key ResultsMost participants were women (N= 9; 82%). Participants reported proficiency in Cantonese, Mandarin, Russian, and Spanish. All fully bilingual participants (n=5) had passed the language assessment; of the partially bilingual participants (n=6), four did not test, one passed with marginal proficiency, and one did not pass. Three themes emerged as barriers to assessment participation: (1) beliefs about the negative consequences (emotional and material) of not passing the test, (2) time constraints and competing demands, and (3) challenging test format and structure. Four themes emerged as facilitators to increase assessment adoption: (1) messaging consistent with professional ethos, (2) organizational culture that incentivizes certification, (3) personal empowerment about language proficiency, and (4) individuals championing certification.ConclusionsTo increase language assessment participation and thus ensure quality language-concordant care, health systems must address the identified barriers physicians experience and leverage potential facilitators. Findings can inform health system interventions to standardize the requirements and process, increase transparency, provide resources for preparation and remediation, utilize messaging focused on patient care quality and safety, and incentivize participation.

Understanding Health Care Utilization and Occupational Exposures of Labor-Trafficked People

Abstract: Objectives. To describe health care utilization and occupational exposures during trafficking among foreign-born people labor-trafficked in the U.S. Methods. Retrospective analysis of immigration files for health data among 114 labor-trafficked individuals. Results. Mean age was 30. Files of 38% mentioned accessing medical services at least once, mostly via hospitals (73%-81%). Forty-three percent (43%) had U.S. citizen children—indicating their children and spouses interacted with social and medical systems during exploitation. Almost all (97%) had limited English proficiency, and 75% did not have legal immigration status. Employers/traffickers interfered with access to health care and forced victims to work while injured. Half (50%) had sick family members. Victims reported physical and sexual abuse, toxic and environmental occupational exposures, and sleep disturbances. Conclusions. This is the largest study to elucidate health concerns and care utilization patterns among labor-trafficked people. Concerted resources must be dedicated to understanding health needs and health systems intervention opportunities for labor-trafficked people.