Levels Of Health System Research Articles

Quality Indicators for Transition from Pediatric to Adult Care for Youth With Chronic Conditions: Proposal for an Online Modified Delphi Study.

The transition from pediatric to adult care poses a significant health system-level challenge impeding the delivery of quality health services for youth with chronic health conditions. In Canada and globally, the transition to adult care is regarded as a top priority in adolescent health in need of readily applicable, adaptable, and relevant national metrics to evaluate and benchmark transition success across disease populations and clinical care settings. Unfortunately, existing literature fails to account for the lack of engagement from youth and caregivers in developing indicators, and its applicability across chronic conditions, primary care involvement, and health equity considerations. Our proposed study aims to establish a consensus-driven set of quality indicators for the transition to adult care that are universally applicable across physical, developmental, and mental health conditions, clinical care settings, and health jurisdictions. Using an integrated knowledge translation (iKT) approach, a panel comprising youth, caregivers, interdisciplinary health care providers, and health system leaders will be established to collaborate with our research team to ensure that the study methodology, materials, and knowledge dissemination are suitable and reflect the perspectives of youth and their families. We will then conduct an iterative 3-round Online Modified Delphi (OMD) study (n=160) to (1) compare and contrast the perspectives of youth, caregivers, health care providers, and health system leaders on quality indicators for transition; and (2) prioritize a key set of quality indicators for transition applicable across disease populations that are the most important, useful, and feasible in the Canadian context. Using the RAND/UCLA Appropriateness Method (RAM) multistage analytic approach, data from each panel and stakeholder group will be examined separately and compared to establish a key set of indicators endorsed by both panels. The study is funded by the Canadian Institutes of Health Research and Physicians Services Incorporated. This study will produce quality indicators to evaluate and inform action equitably to improve transition from pediatric to adult care for youth and their families in Canada. PRR1-10.2196/60860.

Evaluating information management system in epidemic infectious diseases in Iran

Health information management is a vital and constructive component of the health system, refers to the process of producing and collecting, organising and storing, analysing, disseminating and using information. The aim of this study was to evaluate the strengths and weaknesses of the information management system in epidemic infectious diseases in Iran, specifically focusing on the registration, reporting, quality, confidentiality, and security of infectious disease data. This assessment was conducted from the perspective of policymakers and experts responsible for data registration and reporting. After examining the processes of registering and reporting infectious disease data and interviewing experts, a researcher-designed questionnaire was prepared to evaluate the infectious disease information management system. To assess the content validity of the Content Validity Index and Content Validity Ratio Index, a questionnaire was utilized. The reliability of the questionnaire was confirmed using Cronbach's alpha. By employing purposeful sampling and adhering to the inclusion criteria, 150 participants were included in the study. Questionnaires were distributed via email, WhatsApp, or Telegram to employees at various levels of Iran's health and treatment systems who were responsible for registering and reporting infectious disease data. The study encompassed 100 participants who successfully concluded the research. The results highlight that the key strength of healthcare data registration lies in its ability to "depict the epidemic curve during outbreaks of infectious diseases." Conversely, a notable weakness was the "insufficient collaboration from non-academic sectors (e.g., clinics, private laboratories) in registering and reporting infectious diseases. The present study's findings suggest that the issue lies not in the framework itself, but rather in the execution and functionality of the strategies. We can cultivate a repository of reliable and beneficial data by incorporating initiatives like training programs, enforcing regulations with consequences for inadequate data documentation, offering both material and motivational rewards, and streamlining all data collection and reporting systems.

Budget Impact Analysis of Olaparib for the Management of Patients with Homologous Recombination Repair (HRR)-Mutated Castration-Resistant Metastatic Prostate Cancer in Argentina.

The aim of this study was to perform a budget impact analysis (BIA) of introducing olaparib treatment for adult patients with metastatic castration-resistant prostate cancer in Argentina. A BIA model was used to estimate the cost difference between the current scenario (without olaparib) and the new scenario (incorporation of olaparib) for a third-party payer over a 5-year time horizon. The budgetary impact is estimated at the national health system level and by healthcare sectors in Argentina. Input parameters were obtained from the literature and validated by local expert opinion. Direct medical costs were obtained from both the Institute for Clinical Effectiveness and Health Policy (IECS) unit cost database and public data in Argentina. The microcosting estimation was used for key variables of the analysis. All costs are reported in US dollars (US$) as for October 2022 (1 US$ = 152.59 Argentine pesos). One-way sensitivity analyses and scenario analyses were conducted to evaluate the model robustness. The incorporation of olaparib, with a wholesale price per pack of US$3176, was associated with a weighted average of the budget impact per member per month (PMPM) of US$0.0191 for the national health system, being slightly higher than the estimated budgeted high impact threshold (US$0.0153). The PMPM budget impact for a 5-year average ranged between US$0.007 (public sector) and US$0.033 (private sector). The duration of treatment with olaparib was the most influential parameter in the budget impact results. The introduction of olaparib for the treatment of metastatic castration-resistant prostate cancer has a high budget impact for Argentina's health system. These findings are informative to support policy decisions aimed to expand the current treatment landscape for prostate cancer.

Finding the Missing Men with Tuberculosis: A Participatory Approach to Identify Priority Interventions in Uganda.

Gender impacts exposure and vulnerability to TB, evidenced by a higher prevalence of both TB disease and missed TB diagnoses among men, who significantly contribute to new TB infections. We present the formative research phase of a study which used participatory methods to identify gender-specific interventions for systematic screening of TB among men in Uganda. Health facility level data was collected at four Ugandan general hospitals (Kawolo, Gombe, Mityana, and Nakaseke) among 70 TB stakeholders, including healthcare workers, TB survivors, policymakers, and researchers. Using health seeking pathways, they delineated and compared men's ideal and actual step-by-step TB health seeking processes to identify barriers to TB care. The stepping stones method, depicting barriers as a 'river' and each 'steppingstone' as a solution, was employed to identify interventions which would help link men with TB symptoms to care. These insights were then synthesized in a co-analysis meeting with 17 participants including representatives from each health facility to develop a consensus on proposed interventions. Data across locations revealed the actual TB care pathway diverted from the ideal pathway due to health system, community, health worker and individual level barriers such as delayed health seeking, unfavourable facility operating hours and long waiting times that conflicted with men's work schedules. Stakeholders proposed to address these barriers through the introduction of male-specific services; integrated TB services that prioritize X-ray screening for men with cough; healthcare worker training modules on integrated male-friendly services; training and supporting TB champions to deliver health education to people seeking care; and engagement of private practitioners to screen for TB. In conclusion, our participatory co-design approach facilitated dialogue, learning, and consensus between different health actors on context-specific, person-centred TB interventions for men in Uganda. The acceptability, effectiveness and cost effectiveness of the package will now be evaluated in a pilot study.

Exploring The Implementation Challenges Faced By Healthcare Providers In Delivering Services Under Ayushman Bharat -Arogya Karnataka Health Scheme In Bengaluru, Karnataka-A Qualitative Study

Background: Ayushman Bharat-Arogya Karnataka (AB-ArK) is a flagship health insurance scheme of Karnataka started in Oct-2018. The integrated health assurance scheme of Ayushman Bharat-Arogya Karnataka is implemented by the State of Karnataka on an assurance/trust mode through the State Health Agency-Suvarna Arogya Suraksha Trust (SAST). AB-Ark is a Universal Health coverage scheme that provides a comprehensive healthcare to both Below Poverty Line (BPL) and Above Poverty Line (APL) families, covering a wide range of secondary and tertiary healthcare services. This scheme, part of the broader Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), seeks to offer financial protection against catastrophic health expenditures and improve access to quality healthcare services. Learning the experiences and insights from the scheme's implementers can enhance our understanding of how contextual factors impact a program's success. Therefore, it is crucial to examine the different contextual elements that can either support or obstruct the effective execution of a scheme. Objective: To understand the specific obstacles and barriers in effectively implementing the Ayushman Bharat Arogya Karnataka health scheme from a healthcare provider perspective. Methods: The study employed a qualitative approach involving 8 in-depth interviews. Interviews were audio recorded and were transcribed as per the reported verbatim. The transcripts were then analysed in Microsoft excel using thematic analysis for emerging patterns and insights leading to conclusions drawn from the analysis results. Results: Findings were depicted in broad themes and subthemes under individual, community, health system and policy levels. In brief, factors like infrastructure, patient load, awareness, affordability, quality of care and operational challenges were discussed. Conclusion: Study finding revealed various challenges faced by the health care provider, which needs to be addressed for the scheme’s long-term success and sustainability. Continuous monitoring, policy adjustments, and stakeholder engagement are essential to overcoming these hurdles and achieving the scheme's objectives.

Development of a Tool for the Assessment of Job Satisfaction amongst the Community Health Workers

Abstract Introduction: Amongst the various factors influencing the performance of community health workers (CHWs), job satisfaction serves as a potential drive to perform better. This study aimed at developing a tool to measure how well the CHWs are satisfied pertaining to individual, community and health system determinants. Methodology: This cross-sectional study was conducted in a rural block of Madhya Pradesh (Central India). The CHWs were administered a self-reported questionnaire that contained individual, health system and community level determinants of job satisfaction with a 5-point Likert scale to mark their perception. Results: The job satisfaction scale of 15 items was initially administered to the 92 CHWs. Their scale content validity index (average) was 0.83. The finalised tool consisted of 13 items under three factors following the exploratory factor analysis namely, health system, supervision and peer support and intrinsic job satisfaction. Their overall Cronbach’s alpha was 0.81, with the median (interquartile range) score of job satisfaction for both the Relatively Low Performing and Relatively High Performing Community Health Workers being 4 (4–5). Conclusion: The CHWs in this study were satisfied with their performance as voluntary village health workers following the assessment using a complex job satisfaction scale.

Characteristics of women on opioid substitution therapy in primary healthcare in Tshwane (South Africa): a retrospective observational study.

Women who use drugs face specific challenges compared to men, such as higher rates of HIV infection, unsafe injecting practices and intimate partner violence. However, this population's access to drug dependence treatment and gender-sensitive interventions remains limited, leading to unmet needs and increased vulnerability. To investigate the characteristics of and associations with retention in care among women on opioid substitution therapy (OST) in a community based primary care setting. A descriptive observational study within the Community Orientated Substance Use Programme in Tshwane, South Africa. Data from 199 women (>18 years) on OST was extracted from an electronic database and paper-based files. Data was analysed descriptively, and inferential analysis looked for association of variables with retention on OST for≥6 months. Majority of participants were unemployed, with 44.3% falling within the 20-29 years age range. During the initiation and course of OST, 39.2% of women experienced intimate partner violence, and 19.0% were pregnant. Retention on OST was significantly associated with increasing age at initiation (p=0.047), knowledge of HIV status (p=0.029), an increase in the ASSIST score (p=0.023), and methadone dose (p<0.001). Factors such as race, employment status, health system level, pregnancy, intimate partner using substances, intimate partner violence, route of administering opioids, and having tuberculosis and/or hepatitis C exposure did not show a significant relationship with retention on OST (p>0.05). This study reveals specific vulnerabilities in women receiving OST, emphasising the need for the integration of interventions to address reproductive health, violence mitigation, infectious disease and polydrug use into care.

Burden of Congenital CMV Infection: A Narrative Review and Implications for Public Health Interventions.

Cytomegalovirus causes the most common congenital infection worldwide. With most infants asymptomatic at birth, the few affected may present with variable clinical scenarios, from isolated hearing loss to severe neurologic impairment. Public health interventions include all actions at the health system, community, and individual levels that aim at reducing the burden of congenital Cytomegalovirus. This review examines the literature on maternal and neonatal screening programs in light of current evidence for treatment and the development of vaccines against Cytomegalovirus. Potential biases and benefits of these interventions are outlined, with the objective of increasing awareness about the problem and providing readers with data and critical tools to participate in this ongoing debate.

Exploring the barriers, facilitators, and opportunities to enhance uptake of sexual and reproductive health, HIV and GBV services among adolescent girls and young women in Zambia: a qualitative study

IntroductionAdolescents and young women in low-middle-income countries face obstacles to accessing HIV, Sexual and Reproductive Health (SRH), and related Gender-Based Violence (GBV) services. This paper presents facilitators, opportunities, and barriers to enhance uptake of HIV, GBV, and SRH services among Adolescent Girls and Young Women (AGYW) in selected districts in Zambia.MethodsThis study was conducted in Chongwe, Mazabuka, and Mongu Districts among adolescent girls and young women in Zambia. Key informants (n = 29) and in and out-of-school adolescents and young people (n = 25) were interviewed. Purposive sampling was used to select and recruit the study participants. Interviews were transcribed verbatim, and a content analysis approach was used for analysis.ResultsThe facilitators that were used to enhance the uptake of services included having access to health education information on comprehensive adolescent HIV and gender-based violence services. Non-governmental organisations (NGOs) were the main source of this information. The opportunities bordered on the availability of integrated approaches to service delivery and strengthened community and health center linkages with referrals for specialised services. However, the researchers noted some barriers at individual, community, and health system levels. Refusal or delay to seek the services, fear of side effects associated with contraceptives, and long distance to the health facility affected the uptake of services. Social stigma and cultural beliefs also influenced the understanding and use of the available services in the community. Health systems barriers were; inadequate infrastructure, low staffing levels, limited capacity of staff to provide all the services, age and gender of providers, and lack of commodities and specialised services.ConclusionThe researchers acknowledge facilitators and opportunities that enhance the uptake of HIV, GBV, and SRH services. However, failure to address barriers at the individual and health systems level always negatively impacts the uptake of known and effective interventions. They propose that programme managers exploit the identified opportunities to enhance uptake of these services for the young population.

Considering challenges for the new Alzheimer's drugs: Clinical, population, and health system perspectives.

Recent approvals of amyloid immunotherapy drugs for early Alzheimer's disease (AD) have been highly controversial. In this piece, we consider challenges from the clinical, population health, and health systems perspectives to the role that the new AD drugs might be expected to play, now and in the future, in alleviating the morbidity caused by AD in the population. Clinically, short-term effects are small, adverse events are frequent, treatment regimens are burdensome, and, crucially, long-term effects are unknown. At a population level, there is always likely to be a trade-off between breadth of access and magnitude of benefit for any given individual. At a health system level, roll out of treatment even for only narrowly-defined patient groups will involve considerable resources to identify and treat eligible patients, with profound opportunity costs. Our considered view on current evidence is that there are challenges from each perspective to imagining a foreseeable future in which amyloid immunotherapy significantly alleviates AD morbidity at scale. HIGHLIGHTS: Recent approvals of Alzheimer's drugs have met with excitement but also controversy. Trial effects are small, adverse effects concerning, and long-term effects unknown. Results from trial cohorts may not generalize to broader, more complex patients. Significant resource requirements of eligibility assessment and drug administration. Use in "presymptomatic" populations is not supported by current evidence.

Optimizing tracking and completion of follow-up colonoscopy after abnormal stool tests at health systems participating in the Centers for Disease Control and Prevention's Colorectal Cancer Control Program.

We present findings from an assessment of award recipients' partners from the Centers for Disease Control and Prevention's Colorectal Cancer Control Program (CRCCP). We describe partners' processes of identifying and tracking patients undergoing stool-based screening. We analyzed data from eight CRCCP award recipients purposively sampled and their partner health systems from 2019 to 2023. The data included number of stool-based tests distributed and returned; abnormal findings; referrals and completion of follow-up colonoscopies; and colonoscopy findings. We also report on strategies to improve tracking of stool-based tests and facilitation of follow-up colonoscopies. Five of eight CRCCP award recipients reported that all or some partner health systems were able to report stool test return rates. Six had health systems that were able to report abnormal stool test findings. Two reported that health systems could track time to follow-up colonoscopy completion from date of referral, while four could report colonoscopy completion but not the timeframe. Follow-up colonoscopy completion varied substantially from 24.2 to 75.5% (average of 47.9%). Strategies to improve identifying and tracking screening focused mainly on the use of electronic medical records; strategies to facilitate follow-up colonoscopy were multi-level. Health systems vary in their ability to track steps in the stool-based screening process and few health systems can track time to completion of follow-up colonoscopy. Longer time intervals can result in more advanced disease. CRCCP-associated health systems participating in this study could support the implementation of multicomponent strategies at the individual, provider, and health system levels to improve tracking and completion of follow-up colonoscopy.

Accessibility of diabetes education in the United States: barriers, policy implications, and the road ahead.

Diabetes Self-Management Education and Support (DSMES) programs are an effective, yet underutilized, resource to improve health outcomes and behaviors for people with diabetes. We examined the attendance and referral rates for people with diabetes to DSMES classes at an academic medical center, noting a 10% referral rate and 37% completion rate for those referred. We identified barriers to DSMES care at patient, provider, and health system levels. Current technology platforms and training fail to prioritize referrals to diabetes education; providers and people with diabetes are often unfamiliar with program content and benefits. Scheduling mechanisms often delay or lose interested patients in receiving vital education. Existing Medicare reimbursement strategies limit expansion of DSMES programs, generating significant wait times and limit capabilities for Diabetes Care and Education Specialists. We identify potential policy solutions and recommend alterations to existing referral and scheduling systems to expand existing technology platforms for DSMES programs and shift reimbursement policies to individualize and better support care for persons with diabetes.

FRAP 2.0: a community engagement method applied to cervical cancer disparities among Hispanic women

focused Rapid Assessment Process (fRAP) 2.0 is a community engagement approach combining geospatial mapping with rapid qualitative assessment in cyclical fashion within communities to capture multifactorial and multilevel features impacting...

The Role of Empathy, Communication, and Emotional Intelligence in Nursing Service Quality at RSIA Bunda Denpasar

Introduction: Nursing services are an integral part of hospital health services, and they have a very strategic position in efforts to improve the quality of consumer services coming to the hospital. The delivery of quality health services highlights the need for multi-stakeholder action at all health system levels. The hospital can maintain patient loyalty and gain public trust by providing efficient and quality services by providing good service. This study examined the effect of empathy, communication, and emotional intelligence on the quality of nursing services at RSIA Bunda Denpasar.Methods: The design of this study was cross-sectional, using a multivariate test and convenience sampling technique. The independent variables in this study were empathy, communication, and emotional intelligence. Meanwhile, the dependent variable in this study is the quality of nursing services at RSIA Bunda Denpasar. The timing of this study is in May 2024. This study used a sampling of 38 respondents. The instruments in this study used empathy, communication, caring, and nursing service quality questionnaires. A validity test value of 0.650-1,000, 0.790-1,000, 0.500-1,000, and 0.545-1,000, and a reliability test value of 0.877, 0.756, 0.765, and 0.867. Results: the results of the multivariate test showed the significance value of each variable has a significance value of &lt;0.005, so the influence of empathy, communication, and emotional intelligence on the quality of nursing services at RSIA Bunda DenpasarConclusion: It is recommended that health service managers improve the quality of human resources by providing nursing services well.

Should I See You Again Soon? Multispecialty Assessment of Impact and Burden of Preoperative History and Physical Update Visits.

Federal regulations require a history and physical (H&P) update performed 30 days or less before a planned procedure. We evaluated the use and burdens of H&P update visits by determining impact on operative management, suitability for telehealth, and visit time and travel burden. We identified H&P update visits performed in our health system during 2019 for 8 surgical specialties. As available, up to 50 visits per specialty were randomly selected. Primary outcomes were interval changes in history, examination, or operative plan between the initial and updated H&P notes, and visit suitability for telehealth, as determined by 2 independent physician reviewers. Clinic time was captured, and round-trip driving time and distance between patients' home and clinic ZIP codes were estimated. We identified 8,683 visits and 362 were randomly selected for review. Documented changes were most commonly identified in histories (60.8%), but rarely in physical examinations (11.9%) and operative plans (11.6%). Of 362 visits, 359 (99.2%) visits were considered suitable for telehealth. Median clinic time was 52 minutes (interquartile range 33.8 to 78), driving time was 55.6 minutes (interquartile range 35.5 to 85.5), and driving distance was 20.2 miles (interquartile range 8.5 to 38.4). At the health system level, patients spent an estimated aggregate 7,000 hours (including 4,046 hours of waiting room and travel time) and drove 142,273 miles to attend in-person H&P update visits in 2019. Given their minimal impact on operative management, regulatory requirements for in-person H&P updates should be reconsidered. Flexibility in update timing and modality might help defray the substantial burdens these visits impose on patients.

Factors influencing the implementation of the CombiConsultation in Dutch clinical practice: a mixed-methods study.

The CombiConsultation is an innovative concise clinical pharmacy service by the community pharmacist for patients with a chronic condition. We aimed to identify relevant factors influencing the implementation of the CombiConsultation in Dutch clinical practice. A mixed-methods study involving interviews and a questionnaire. Content analysis topics within TDF domains were derived from the interview data and were related to the COM-B-model (capability-opportunity-motivation-Behaviour). The relevance of the resulting topics was explored using a questionnaire with 19 statements administered to all 27 pharmacists who performed CombiConsultations. Eighteen topics emerged from the interviews. The questionnaire was completed by 23 of the 27 pharmacists. In the domain 'capability', a small number of participants indicated that they need more expertise in pharmacotherapy (13%) and training in consultation skills (35%). In the domain 'opportunity', all participants indicated that an existing good collaboration with the general practitioner/practice nurse and access to all relevant medical data were necessary to implement the CombiConsultation. In terms of motivation, job satisfaction was most important to all participants, followed by adequate reimbursement (83%) and improving collaboration with other healthcare providers and the relationship with patients (78%). Capability, opportunity, and motivation were all considered relevant for the implementation of the CombiConsultation. There were crucial factors on the level of the individual pharmacist, on the level of the local collaboration and organization, and on the health system level.

The Use of COVID-19 Mobile Apps in Connecting Patients with Primary Healthcare in 30 Countries: Eurodata Study.

The COVID-19 pandemic has necessitated changes in European healthcare systems, with a significant proportion of COVID-19 cases being managed on an outpatient basis in primary healthcare (PHC). To alleviate the burden on healthcare facilities, many European countries developed contact-tracing apps and symptom checkers to identify potential cases. As the pandemic evolved, the European Union introduced the Digital COVID-19 Certificate for travel, which relies on vaccination, recent recovery, or negative test results. However, the integration between these apps and PHC has not been thoroughly explored in Europe. To describe if governmental COVID-19 apps allowed COVID-19 patients to connect with PHC through their apps in Europe and to examine how the Digital COVID-19 Certificate was obtained. Design and setting: Retrospective descriptive study in PHC in 30 European countries. An ad hoc, semi-structured questionnaire was developed to collect country-specific data on primary healthcare activity during the COVID-19 pandemic and the use of information technology tools to support medical care from 15 March 2020 to 31 August 2021. Key informants belong to the WONCA Europe network (World Organization of Family Doctors). The data were collected from relevant and reliable official sources, such as governmental websites and guidelines. Patient's first contact with health system, governmental COVID-19 app (name and function), Digital COVID-19 Certification, COVID-19 app connection with PHC. Primary care was the first point of care for suspected COVID-19 patients in 28 countries, and 24 countries developed apps to complement classical medical care. The most frequently developed app was for tracing COVID-19 cases (24 countries), followed by the Digital COVID-19 Certificate app (17 countries). Bulgaria, Italy, Serbia, North Macedonia, and Romania had interoperability between PHC and COVID-19 apps, and Poland and Romania's apps considered social needs. COVID-19 apps were widely created during the first pandemic year. Contact tracing was the most frequent function found in the registered apps. Connection with PHC was scarcely developed. In future pandemics, connections between health system levels should be guaranteed to develop and implement effective strategies for managing diseases.

Adolescent girls and young women’s (AGYW) access to and use of contraception services in Cape Town: perspectives from AGYW and health care providers

BackgroundAccess and use of contraception services by adolescent girls and young women (AGYW) remains suboptimal, exposing AGYW to early and often unexpected pregnancy. Unexpected pregnancies are a public health concern, associated with poor neonatal and maternal health outcomes, as well as school dropout, which may result in economic hardships. This study aimed to explore (a) AGYW perceptions and experiences of receiving contraception services from health care providers and (b) health care providers’ perceptions and experiences of providing contraception services to AGYW.MethodsData were collected through semi-structured individual interviews with AGYW aged 15–24 years old and health care providers working in eight health care facilities around the Cape Town metropolitan area, in South Africa’s Western Cape Province. Thematic analysis was used to analyse the data.ResultsAGYW and health care providers voiced varying, and often contrasting, perceptions of some of the barriers that hinder AGYW’s access to contraception services. AGYW indicated that provider-imposed rules about when to access contraceptive services hindered access, while health care providers felt that these rules were necessary for coordinating their work. In addition, AGYW highlighted health care providers’ hostile attitudes towards them as an important factor discouraging access. On the contrary, health care providers did not think that their attitudes hampered AGYW’s access to and use of contraception services, instead they emphasised that challenges at the health system level were a major issue, which they feel they have little control over. Such challenges made health care providers’ work unpleasant and frustrating, impacting on their work approach and how they receive and offer services to AGYW.ConclusionThe expectation of negative attitudes from health care providers continues to be at the centre of AGYW discouragement towards accessing contraception services. System challenges are among some of the key drivers of health care provider’s hostile attitudes, posing challenges to the efficient provision of services. In order to improve AGYW’s access to and use of contraception services, and subsequently achieve the country’s SDGs, conscious efforts need to be directed towards improving the workload and working conditions of health care providers.

Healthcare system barriers and facilitators to hypertension management in Ghana.

Background: Hypertension continues to pose a significant burden on the health systems in Sub-Saharan Africa (SSA). Multiple challenges at the health systems level could impact patients' blood pressure outcomes. There is a need to understand the gaps in health systems to improve their readiness to manage the rising burden of hypertension Objective: To explore health system barriers and opportunities for improved management of hypertension in Ghana, West Africa. Methods: We conducted 5 focus group discussions involving 9 health facility leaders and 24 clinicians involved in hypertension treatment at 15 primary-level health facilities in Kumasi, Ghana. We held discussions remotely over Zoom and used thematic analysis methods. Results: Four themes emerged from the focus group discussions: (1) financial and geographic inaccessibility of hypertension services; (2) facilities' struggle to maintain the supply of antihypertensive medications and providers' perceptions of suboptimal quality of insured medications; (3) shortage of healthcare providers, especially physicians; and (4) patients' negative self-management practices. Facilitators identified included presence of wellness and hypertension clinics for screening and management of hypertension at some health facilities, nurses' request for additional roles in hypertension management, and the rising positive practice of patient home blood pressure monitoring. Conclusion: Our findings highlight critical barriers to hypertension service delivery and providers' abilities to provide quality services. Health facilities should build on ongoing innovations in hypertension screening, task-shifting strategies, and patient self-management to improve hypertension control. In Ghana and other countries, policies to equip healthcare systems with the resources needed for hypertension management could lead to a high improvement in hypertension outcomes among patients.

Barriers and Facilitators for Implementing Shared Decision Making in Differentiated Antiretroviral Therapy Service in Northwest Ethiopia: Implications for Policy and Practice

Background. Shared decision making (SDM) for patients enrolling in differentiated antiretroviral therapy (DART) is crucial. Empirical evidence is lacking regarding factors promoting or hindering SDM implementation in DART provision in Ethiopia. Hence, this study aimed to explore the barriers and facilitators to implementing SDM for patients enrolled in DART in Northwest Ethiopia. Methods. A qualitative descriptive study using semi-structured interviews among 17 patients and 15 providers at health facilities providing DART service was conducted. The MAXQDA version 20 software was used for inductive coding. Interviews were analyzed using thematic analysis. Results. Ten themes emerged at 4 levels related to SDM in the provision of DART: patient, provider, organizational, and health system. At the patient level, 1) trust in providers (facilitator) and 2) patient’s level of education (barrier) emerged as themes. At the provider level, 3) lack of familiarity with DART models (barrier) and 4) patient-provider relationship (barrier and facilitator) were emerged themes. At the organizational level, 5) workload (barrier) and 6) resources (barrier and facilitator) emerged as themes. At the health system level, 7) availability of DART models (facilitator), 8) not involving providers while initiating DART models (barrier), 9) other providers’ involvement (facilitator), and 10) presence of other implementing partners (barrier) emerged as themes. Conclusions. Numerous barriers and facilitators influence the implementation of SDM in the provision of DART. Based on these findings, the following steps are recommended. Providing access to patient decision aids shall be in place to assist patients in making decisions about their preferred DART models. Health care workers shall be trained, and patients shall be given education to enhance the SDM process. Policy makers and program managers shall consider the resource context (training and size of human resources and convenience of rooms) for the delivery of ART service to have an appropriate implementation of SDM in clinical practice. Highlights Shared decision making in DART is influenced by various barriers and facilitators present at the patient, provider, organizational, and health system levels. Patients need education, and health care staff need regular training to improve SDM in DART service provision. Patient access to decision support tools that aid in the selection of the preferred DART model in health facilities is critical. Policy makers and program managers shall consider the availability of adequate and trained human resources as well as provide adequate space and private rooms for SDM in the implementation of DART.