Local Staff Research Articles

Building capacity for the use of systems science to support local government public health planning: a case study of the VicHealth Local Government Partnership in Victoria, Australia

ObjectiveTo present an approach to build capacity for the use of systems science to support local communities in municipal public health and well-being planning.DesignCase study.SettingLocal government authorities participating in the...

Developing an Ethnographic Community‐Based Participatory Research Dementia Study with Diverse Indigenous Populations: Indigenous Cultural understandings of Alzheimer’s disease and related dementias – Research and Engagement (ICARE) project

AbstractBackgroundDementia diagnoses have been increasing in Indigenous populations for over a decade and have now surpassed rates in non‐Indigenous populations in both Canada and the U.S. Prevalence rates of Alzheimer’s Disease and Related Dementias (ADRD) are approximately 3 times higher in Indigenous populations compared to White populations, with a 10‐year earlier onset . The ICARE project (NIH –5R56‐AG‐62307‐2) qualitatively explores the impact of ADRD in Indigenous populations across four diverse sites in Canada and the United States.MethodWe used a community‐based participatory research (CBPR) approach and a two‐eyed seeing framework to establish research partnerships with four Indigenous communities/regions: 7 Anishinaabe First Nations on Manitoulin Island, Ontario Canada; Red Lake Tribal Nation, Minnesota; Grand Portage Tribal Nation, MN; and the Oneida Nation, Wisconsin. The community engagement strategy supported the infrastructure needed to conduct dementia research in a culturally safe and appropriate way that respects Tribal Sovereignty.ResultIndigenous community‐based researchers were hired at each site and each underwent research training designed by the ICARE team. With guidance from local leadership, we established 8–12‐member community advisory groups at each site to serve as partners to guide the research. We collected preliminary ethnographic data on social determinants of health, demographics, community health, aging and dementia specific services. We demonstrated feasibility with pilot data collection of key informant interviews with Traditional Knowledge Keepers, Administrators, and Providers (n = 54) and sequential focus groups with local health care staff and formal caregivers that work with Indigenous older adults (n = 17).ConclusionNIH/NIA R56 funding resulted in the establishment of the community‐based infrastructure to support on‐going ADRD research in the four diverse communities. We demonstrated the feasibility of supporting community‐engaged dementia research partnerships with Indigenous communities who have differing cultural, political and historical contexts. This foundation is supporting the expansion of ICARE into a 5‐year ethnographic research study aimed at creating a foundational ethnographic database of AI/FN lived experience of ADRD across the disease trajectory that can be examined to inform the creation of culturally appropriate and safe approaches to improve dementia diagnostics, care, and outreach (NIH‐R01‐AG‐62307‐2).

Embedding electronic patient-reported outcome measures into routine care for patients with stage III MELanoma (ePROMs-MEL): protocol for a prospective, longitudinal, mixed-methods pilot study

IntroductionThe benefits of patient-reported feedback, using questionnaires that allow patients to report how they feel and function without any interpretation from healthcare professionals, are well established. However, patient-reported outcomes measures...

What does it take to get a diagnosis? Dementia recognition and diagnosis pathways among Indigenous peoples

AbstractBackgroundPatients, caregivers, and providers face an oftentimes‐confusing healthcare terrain around dementia diagnostics and care given the lack of standardization for screening and evaluation of neurocognitive disorders. This can be further compounded by systemic healthcare inequalities and historical and present‐day marginalization faced by Indigenous populations.MethodWe present a segment of a pilot study (NIH R56 AG 62307) which sought to explore the impact of Alzheimer’s disease and related dementias (ADRDs) in Indigenous populations across four diverse settings, three in the United States and one in Canada. Community‐based researchers conducted key informant interviews with healthcare providers (n = 20) and sequential focus groups (SFGs) with local health care staff and formal caregivers (14 sessions, n = 17). Data were coded based on research questions and objectives in consultation with project leaders, coders, and community‐based researchers.ResultIn recognizing a cognitive change, all participants identified the importance of family members who often brought their concerns to the attention of a healthcare provider. Additionally, participants in the US and Canada identified events like hospital admissions as a “catastrophic event” (e.g., injury, missed medication, physical decline) as another route for diagnosis. A unique pathway that Canadian participants identified was the role of personal support workers (PSWs) and community nurses in noticing cognitive changes among individuals they served. Finally, providers mentioned various pathways for receiving a dementia diagnosis. While all providers mentioned taking steps to rule out other reasons for cognitive decline, the specific next step for the diagnosis varied widely. The possible professionals to see for a diagnosis included social workers, family doctors, tribal dementia care specialists, behavioral health specialists, psychiatrists, and neurologists.ConclusionFamily members are crucial in recognizing the changes associated with ADRDs. A strength of the Canadian healthcare system is that PSWs and community nurses can also help identify changes, potentially before hazardous “catastrophic events” bring people to the hospital. Once a cognitive change has been identified, the diagnostic pathway is complicated, non‐standardized, and irregular – in other words difficult to navigate. Policies and procedures need to be put in place, delineating standardized protocols to better help family caregivers and patients dealing with ADRDs.

Innovation in simulation: reducing the cost

Simulation equipment is often prohibitively expensive. More so for smaller remote settings and developing countries. Reducing costs is essential to increase widespread uptake of high-fidelity simulation tools. We describe the evolution of a cooperative simulation model development team incorporating the local Emergency Medicine Department clinical staff and local Secondary school pupils. This was a symbiotic relationship that utilised the clinical expertise of the doctors while giving the students project management experience while using the significant resources of the schools for physical product development. Roughly 15,000 tracheostomies are performed each year in the UK. After looking further in depth at emergency tracheostomies, we recognised a gap in this area of healthcare training [1]. Consequently, developing a surgical airway trainer was selected as the model to produce over the course of an academic year. The partnership project required infrequent visit from the clinical team to inform on clinical particulars and review model progression. Ultimately 2 models were selected from various prototypes to take to completion. These represented 3 core areas we wished to develop. The first model was a high-fidelity model completed using latest technology available in the school’s workshops. The second was built with minimal technology and aimed to be reproducible following simple instructions with widely available materials and be completely biodegradable. This project resulted in successful development of two surgical airway models – both clinically and anatomically accurate, reusable, which deliver high quality simulation to a group of doctors and students at the local hospital. Both models are easily reproducible with minimal skills, but varied in both the detail and tools required to produce and degree of sustainability. Maximum cost of materials was £15. Partnership with local schools gives hospitals access to resources not otherwise available that can lead to the development of innovative simulation models that can significantly reduce the cost of simulation. Both parties gain significantly from this partnership. Going forwards we aim to continue the partnership with aims to develop a central line training model over the next academic year. 1. Taylor C. Training for tracheostomy. BJA: British Journal of Anaesthesia. 2013;111(5):842–843.

Factors associated with healthcare-seeking behavior for symptomatic acute respiratory infection among children in East Africa: a cross-sectional study

BackgroundAlthough there has been promising progress in the reduction of child mortality from ARI, the magnitude is high yet, especially in East Africa. Since mothers/guardians decide upon the type and frequency of healthcare services for children, their good healthcare-seeking behavior could prevent acute respiratory infections (ARI) related mortality and morbidity. This study aimed to investigate the pooled prevalence and factors associated with healthcare-seeking behavior of children younger than five years with ARI symptoms by using data from nationally representative surveys of East Africa.MethodsWe analyzed secondary data based on the eleven East African Demographic and Health Survey data. Both Individual and community level variables were considered for this study and a multilevel binary logistic regression model was fitted to identify associated factors of children’s healthcare-seeking behavior for ARI symptoms. STATA V.14 software was used to clean, recode and analyze the data. All variables with a p-value = 0.2 in the bi-variable analysis were considered for the multivariable multilevel analysis. Adjusted OR (AOR) with 95% CI was reported to reveal significantly associated factors in the multivariable multilevel analysis.ResultThe overall prevalence of healthcare-seeking behavior of under-five children for ARI symptoms was 64.4% in East Africa. In the multilevel analysis, the following characteristics were found to be the most important factors of children healthcare seeking behavior for ARI symptoms (P < 0.05): Rural residence [AOR = 0.51, 95% CI (0.37–0.65)], high community level media usage [AOR = 1.63, 95% CI (1.49–1.79)], high community level women education [AOR = 1.51, 95% CI (1.39–1.66)], primary education [AOR = 1.62, 95% CI (1.45–1.82)], secondary education and above [AOR = 1.99, 95% CI (1.71–2.32)], working mother [AOR = 1.33, 95% CI (1.20–1.48)], unmarried women [AOR = 1.15, 95% CI (1.04–1.27)], media access [AOR = 1.43, 95% CI (1.20–1.58)], richest [AOR = 1.39, 95% CI (1.29–1.51)], distance to health facility not a big problem [AOR = 1.11, 95% CI (1.02–1.21)], Place of delivery at health facilities [AOR = 1.77, 95% CI (1.60–1.95)], age of child 7–23 months [AOR = 1.59, 95% CI (1.39–1.82)], age of child 24–59 months [AOR = 1.24, 95% CI (1.09–1.41)] in comparison with children aged 0–6 months, family size > 10 [AOR = 1.53, 95% CI (1.22–1.92)].Conclusions and recommendationsThe overall prevalence of children’s healthcare-seeking behavior for ARI symptoms was found relatively low in East Africa, ARI symptoms were determined by individual-level variables and community-level factors. Targeted interventions are needed to improve socioeconomic and health systems to overcome the problem of acute respiratory infection in children. Special attention is required to empower local health staff and health facilities to provide proper diagnosis and management of ARI cases in East Africa.

How much does effective health facility inspection cost? An analysis of the economic costs of Kenya’s Joint Health Inspection innovations

BackgroundIn most low- and middle-income countries, health facility regulation is fragmented, ineffective and under-resourced. The Kenyan Government piloted an innovative regulatory regime involving Joint Health Inspections (JHI) which synthesized requirements across multiple regulatory agencies; increased inspection frequency; digitized inspection tools; and introduced public display of regulatory results. The pilot significantly improved regulatory compliance. We calculated the costs of the development and implementation of the JHI pilot and modelled the costs of national scale-up in Kenya.MethodsWe calculated the economic costs of three phases: JHI checklist development, start-up activities, and first year of implementation, from the providers’ perspective in three pilot counties. Data collection involved extraction from expenditure records and key informant interviews. The annualized costs of JHI were calculated by adding annualized development and start-up costs to annual implementation costs. National level scale-up costs were also modelled and compared to those of current standard inspections.ResultsThe total economic cost of the JHI pilot was USD 1,125,600 (2017 USD), with the development phase accounting for 19%, start-up 43% and the first year of implementation 38%. The annualized economic cost was USD 519,287, equivalent to USD 206 per health facility visit and USD 311 per inspection completed. Scale up to the national level, while replacing international advisors with local staff, was estimated to cost approximately USD 4,823,728, equivalent to USD 103 per health facility visit and USD 155 per inspection completed. This compares to an estimated USD 86,997 per year (USD 113 per inspection completed) spent on a limited number of inspections prior to JHI.ConclusionInformation on costs is essential to consider affordability and value for money of regulatory interventions. This is the first study we are aware of costing health facility inspections in sub-Saharan Africa. It has informed debates on appropriate inspection design and potential efficiency gains. It will also serve as an important benchmark for future studies, and a key input into cost-effectiveness analyses.

A Qualitative Study Assessing Haitian Pediatric Nursing Educational Needs in Port-au-Prince, Haiti.

After Port-au-Prince's 2010 earthquake, Hospital Bernard Mevs (HBM) developed a collaboration with international medical volunteers to provide clinical care and medical resources; that evolved to include medical education as local Haitian staffing developed. There has been limited coordination among volunteers and local providers about ways in which volunteers can best serve the hospital, and literature that addresses how to coordinate volunteer efforts to support the educational needs of the local nursing staff is scant. Our objectives were to complete an educational needs assessment of the most common diagnoses encountered, requested topics for education, and preferred learning modalities as reported by Haitian pediatric nurses, and categorize the strengths of HBM and barriers to care to understand more fully the context within which nurses function, and how education and international volunteers may be related. In October 2019, 10 HBM pediatric nurses participated in small-group interviews. Questions were based on an interview guide and responses were coded and analyzed for recurring themes. The most common diagnoses were sepsis, hydrocephalus, and hypoxic ischemic encephalopathy. Topics for review included chest tubes, ventilator management, and ventriculoperitoneal shunts. Preferred learning modalities were didactics and hands-on workshops. Strengths of the hospital were team dynamics and education provided by HBM and international volunteers, whereas the most common barrier to care was lack of clinical supplies. This information is useful to guide future educational interventions, and this model may inform other programs with a volunteer presence in resource-limited settings to promote collaboration and self-directed learning.

Use of YEARS Algorithm in Military Health Care Beneficiaries to Evaluate Use of Computed Tomography Pulmonary Angiography.

Pulmonary embolism (PE) can be difficult to rule out without computed tomography pulmonary angiograms (CTPAs), as presentations vary. Multiple clinical decision rules (CDRs) exist to risk-stratify patients to avoid unnecessary CTPAs. However, the currently used CDRs are complex, and research has shown low compliance with their usage. The YEARS algorithm is less complex and excludes patients from CTPA if PE is not the most likely diagnosis, they do not have a history of hemoptysis, and no clinical signs of deep vein thrombosis, is less complex. However, no studies have evaluated YEARS in the U.S. Military health care beneficiary population. Therefore, this study sought to determine if implementing the YEARS algorithm could decrease the number of CTPAs ordered to rule out PE in low-risk patients. This retrospective, single-center cohort study applied the YEARS algorithm to low-risk military beneficiaries presenting to the emergency department in the calendar year 2020 at a single U.S. Army MTF. The primary outcome was the number of CTPAs indicated by the YEARS algorithm versus the number ordered via standard practice. We used chi-square testing to compare the number of subjects in whom YEARS indicated CTPA (meets criteria/does not meet criteria) versus the actual number of subjects who underwent CTPA (meets criteria/does not meet criteria). The secondary outcomes included applying YEARS similarly to the number of subjects >50 years of age (as opposed to age-adjusted d-dimer), determining the number of pregnant patients who could have avoided CTPA via application of YEARS, and assessing possible cost savings via reduction of CTPA. We included 353 subjects during the study period, 271 of whom underwent CTPA. YEARS would have only indicated 25 of them, P = .018. In patients >50 years of age, 164 underwent CTPA versus nine who met YEARS criteria, P = .014. Among pregnant patients, six underwent CTPA versus one who YEARS would have indicated, P = .130. Application of the YEARS algorithm would have led to a 90.8% reduction in CTPAs ordered with an overall known missed PE rate of 1.1%. Applying the YEARS algorithm in 2020 could have led to 246 fewer CTPAs at a minimum cost savings of $38,762.22 for the MTF based on the coded billing cost of $157.57 per CTPA when local staff radiologists performed image interpretation. This estimate does not consider the additional undisclosed cost of contracted radiologists interpreting after regular duty hours. For our military beneficiaries, our study indicates that the YEARS algorithm would have reduced CTPA utilization in all age ranges and potentially among pregnant patients with a known missed PE rate of 1.1%.

Building COVID-19 Capacity with a Simple Tool – “POP-O-MOP” in the Pacific

Background/Introduction:The COVID-19 pandemic resulted in multiple requests for EMT assistance in the Pacific Region. AUSMAT responded in six countries, sometimes simultaneously. The needs of the pandemic and the pressures on available resources to respond required development of innovative methods. One example is the “POP-O-MOP” tool.Objectives:Describe the evolution and utility of “POP-O-MOP” tool in building local capacity in Pacific health care systems facing COVID-19 outbreaks.Method/Description:The initial aim of the tool was to assist in maximizing the response by providing a concise, one-page teaching tool to assist in training of local nursing staff. As the tool evolved over successive COVID-19 deployments in the Pacific Region, the scope grew to include medical and allied health staff, and the content was refined.While the “POP-O-MOP” mnemonic provides an aide-memoir for steps of COVID-19 care at the bedside; it also provided a structure for facilitating training and interdisciplinary discussion amongst clinicians.Results/Outcomes:By utilizing this structured training face-to-face, video, and online formats, the number of staff able to treat COVID-19 patients was increased, drawing on novices and staff from non-critical care backgrounds.Of significance, it was observed that while the technical skills included improved health response, the confidence gained by local staff in the brief training increased their desire to contribute to the COVID-19 response by overcoming stigma, fear, and the sense of futility.Conclusion:The POP-O-MOP tool proved to be an effective tool to leverage in-country resources by providing effective just-in-time training for local health care workers.

Rehabilitation in EMTs: AUSMAT COVID-19 Deployments

Background/Introduction:The WHO has recommended the inclusion of rehabilitation capabilities in EMTs responding to disasters and health emergencies since 2013. Likewise, the importance of rehabilitation input across the continuum of care for patients experiencing COVID-19 illness has been highlighted since the onset of the global COVID-19 pandemic. Despite recognition of the role and value of rehabilitation, both in EMTs and the management of COVID-19, evidence that EMTs activated in response to COVID-19 have deployed rehabilitation professionals remains limited.Objectives:This paper will describe the experiences of the Australian Medical Assistance Team (AUSMAT) in deploying rehabilitation professionals as an integrated capability of multi-disciplinary EMTs responding to COVID-19 health emergencies.Method/Description:In response to COVID-19 emergencies in Papua New Guinea, Fiji, Timor-Leste, and the Solomon Islands, AUSMAT deployed rehabilitation professionals alongside multi-disciplinary EMTs on four occasions in 2021-2022. The rehabilitation professionals engaged in direct clinical care and capacity-building activities.Results/Outcomes:The work of the deployed AUSMAT rehabilitation professionals facilitated important capacity building and support for local rehabilitation staff and services, enhanced the time critical multi-disciplinary training of local nursing and medical staff, and improved the quality of clinical care of COVID-19 patients.Conclusion:AUSMAT’s experience has demonstrated that the deployment of rehabilitation professionals as part of a multi-disciplinary team adds significant value to the work of EMTs responding to COVID-19 health emergencies. Nursing and medical staff cannot readily replicate the knowledge, skills, and perspectives of rehabilitation professionals. Appropriately skilled rehabilitation professionals should be deployed to support national rehabilitation staff when EMTs respond to health emergencies.

Team Well-Being and Challenges of Deploying an EMT Halfway Around the World

Background/Introduction:UK-Med, as part of our UK EMT project, deployed a team to respond to the overwhelming surge in COVID-19 cases in Papua New Guinea in late 2021. Such deployment was associated with several risks, including natural hazards; earthquakes; societal crisis; tribal fighting and civil unrest; and health risks such as extreme temperatures and poor sanitation infrastructure presented further hazards to personnel safety.Objectives:To share lessons learned on enhancing the well-being of an EMT in a challenging context such as PNG.Method/Description:Satisfaction survey, bilateral meetings, in addition to weekly meetings with the headquarters held throughout the deployment.Results/Outcomes:All deployed team members felt exhausted early in the deployment, including an early lack of clarity on the deployment location which eventually ended up being Mount Hagen, a very risky area only accessible by plane. Utilizing emotional and social support, diversity acceptance within the team, and coherent coordination between team members the deployment delivered upon all agreed objectives. Local staff were integrated and a successful workplan was well-received and evaluated as making a real difference to the staff and patients, with a request for an extension of activities received from the Provincial Health Authority.Conclusion:Considerations for staff well-being need to counter-balance the need for strict security protocols. Solid feedback mechanisms should be designed and implemented at an early stage of deployments to avoid any adverse effect on the team’s well-being. Deployment of an assessment team should strengthen coordination, ensuring required needs are being responded to and operational planning is location/context specific.

Ethics of evaluation for socio-ecological transformation: Case-based critical systems analysis of motivation, power, expertise, and legitimacy

Evaluation that supports social, ecological, and governance systems change and transformation raises ethical questions about what and whose worldviews do and should ground evaluative processes. This article illustrates one approach to ethical analysis within a case study of the first phase of an initiative to co-create a monitoring, evaluation, and learning system. The case drew on the principles of Blue Marble Evaluation in partnership with local staff and Indigenous leaders of the Amazon Sacred Headwaters Initiative. The approach uses critical and relational systems thinking to examine the sources of motivation, power, knowledge, and legitimacy that influence and should influence an evaluation system. Results reframe typical early phase evaluation process work from a contractual agreement to a co-created ethical space that engenders the legitimacy of the evaluation process. Contributions include a conceptual framework and process for ethical analysis that could be adapted by others.

Enhancing COVID 19 vaccination coverage in Sierra Leone

Abstract The project aim to support Sierra Leone in enhancing vaccination coverage. BACKGROUND In November 2021, the vaccination coverage rate was 7% for one dose and 4% for two. According with EPI program, the main problem was not the lack of vaccines (already provided by different donors) but the need of support (training, motivation, allowances) to health personnel. Lombardy project involved 31 local vaccination teams performing a refresh training, followed, by micro-planning meetings. SIGNIFICANCE The Covid epidemiology in SL is not well known, but the possible new waves makes this intervention a high public health priority. USEFULNESS. The model is based on training, motivation, follow up and a very simple monetary allowance system based on performance. An online daily report available on smartphone was provided to follow up performances and manage allowances system. PROBLEM The objective was a donation of vaccines, but after a short assessment the issue changed to the need of supporting the local health staff. The goal shifted to train, give incentives for health workers, support to micro-planification and also to work on timely reporting to follow up the project results. QUESTIONS ANSWERED. Can support to microplanning be effective in enhancing vaccination numbers? Can monetary incentives to personnel based on performances enhance vaccination numbers? Can a setting approach (school, workplaces,..) enhance vaccinations numbers? RESULTS the numbers of vaccination Increased from an average of 5 per team by day in early December (after the refresh training) up to an average of 15 by day after the support to micro-planning, the monetary progressive incentives based on performance and the introduction of settings approach. Up to 85.000 doses was performed in 4 months. Key messages • Planning, performance based payement and training can enhance vaccination coverage. • African countries can performe good vaccination programs if supported in organization and non only in vaccine donation.

Examining the influences on the use of behavioural science within UK local authority public health: Qualitative thematic analysis and deductive mapping to the COM-B model and Theoretical Domains Framework.

Behavioural science and its contribution towards improving public health is receiving increased recognition. Yet, the translation of these insights into public health practice is under-researched. This study explored the factors influencing the use of behavioural science within public health at a local authority level. Fourteen local authority staff (n = 13 female) in the south of England participated in semi-structured interviews, which were analysed inductively to identify key themes. These were later mapped deductively to the COM-B model and Theoretical Domains Framework. Nine themes were identified as factors that influence the use of behavioural science in local authority public health: (1) "Limited past experience," (2) "Narrow understanding," (3) "Perceived value of behavioural science," (4) "Translational gap from theory-to-practice," (5) "No protected time," (6) "Old ways of working," (7) "Political influence and organisational culture," (8) "Relationships with key stakeholders," (9) "Access to behavioural science resources". Deductive mapping of these themes revealed that five of the COM constructs (excluding Physical Capability) and eleven of the TDF domains influenced behavioural science use, with "Social influences" and "Knowledge" being the most prominent. Use of behavioural science within local authority public health practice is limited and inconsistent. For it to be successfully implemented, there must be an understanding of its role and value, alongside strategies to overcome a translational gap from theory to practice. Public health teams would benefit from protected time to enable application and strategies to break old habits of using a common-sense approach. System-wide buy-in, particularly related to senior leadership and system partners is needed, which would benefit from organisational and political culture change. Training opportunities, practical resources and expert in-house support should be considered a priority across public health teams.

Impact of Staff Localization on Turnover: The Role of a Foreign Subsidiary CEO.

Great resignation has become a critical issue in management discipline and retaining talents is one of the most important properties across the globe. Among them, local staff have been regarded as an essential competitive advantage for multinational companies and their sustainability. In this sense, staff localization has received considerable attention from scholars and professionals; however, few studies have examined the mechanisms underlying the relationship between staff localization and turnover. This study examines the macro-level relationship between the ratio of local staff in a subsidiary and the actual turnover rate of 89 multinational companies in 25 countries through their headquarters and subsidiary staff. Additionally, the aim of this study was to identify the moderating impact of a CEO’s nationality. The results showed that local staff leave organizations in which there are more expatriates deployed from HQs. Furthermore, the CEO’s nationality buffered the relationship between staff localization and the local staff turnover. This study can contribute to the academia and practice by revealing the effect of staff localization on staff turnover. In addition, a CEO staffing strategy focusing on nationality can be considered an important factor in retaining competitive local staff during the COVID-19 pandemic for multinational companies.

Municipal community centers as healthy settings: evaluation of a real-world health promotion intervention in Jerusalem

BackgroundThis study presents an intervention designed to foster the implementation of health promotion programs within District Municipality Community Centers (DMCCs) in Jerusalem, and the creation of a peer network of healthy settings with a shared aspiration of collaborating and implementing health-promoting policies at the community level. We also present the evaluation strategy, based on the EQUIHP and RE-AIM frameworks.MethodsTwenty DMCCs completed our program. This evaluation research involved a comprehensive seminar during the first year for DMCCs coordinators, teaching them the principles of health promotion. An educational kit was distributed during the second year. The evaluation strategy included a process evaluation and annual evaluations based on the EQUIHP and RE-AIM frameworks. The EQUIHP tool was divided into four dimensions of evaluation: 1) Framework of health promotion principles, 2) Project development and implementation, 3) Project management, and 4) Sustainability; while the RE-AIM domains included: 1)Reach, 2)Effectiveness, 3)Adoption, 4)Implementation and 5)Maintenance.ResultsThe program led to high responsiveness among DMCCs and to the implementation of diverse health promotion initiatives, with a participation of approximately 29,191 residents. The EQUIHP evaluation showed an improvement in program quality in Year 2. The final RE-AIM evaluation presented a total median score of 0.61 for all domains, where 0 was non-performance and 1.0 was full performance. The ‘Framework of health promotion principles’ and ‘Reach’ components received the highest median score (0.83, 1.0 and 0.87), while the ‘Sustainability and ‘Maintenance’ components received the lowest (0.5).ConclusionsThis innovative program adapts the Healthy Cities approach (initiated by the World Health Organization in 1986) to the development of community center health-promoting settings within the larger municipal framework, training local community center staff members to assess and address local health concerns and build community capacity. The local focus and efforts may help community actors to create health promotion programs more likely to be adopted, feasible in the ‘real-world’ and able to produce public health impact in the communities where people live. Moreover, collaboration and cooperation among DMCCs may lead to a broader community health vision, forging coalitions that can advocate more powerfully for health promotion.Trial registrationNIH trial registration number: NCT04470960.Retrospectively registered on: 14/07/2020.

Federalization of Agriculture Sector: Issues and Challenges

The research examines the current issues and challenges of sectoral restructuring and assesses local governments' performance in agricultural service delivery at the local level under the federal system in Nepal. This study was conducted using a mixed method during 2019-2021 in three local governments at the local, Karnali Province, and federal levels. Qualitative methods such as KIIs, FGDs and field observations were used to analyze the issues and gaps in functions, institutions and policies in the agriculture sector under the federal system. Whilst qualitative methods and an empirical survey among 300 farming households were conducted to assess local governments' performance in agricultural service provisions. The qualitative data were analyzed using the thematic analysis method, and the quantitative data were analyzed using descriptive statistics such as frequency and percentage. Findings revealed that functional overlap, duplication and lack of coordination between the three tiers of the government as major issues in sectoral restructuring. Farming household surveys revealed that local governments are effective in the timely delivery of agricultural services. However, farmers indicated their lower level of agreement on the capacity of the local staff, policies, institutional mechanisms, participatory process in planning and financial resource allocation for agricultural services. The performance of these three local governments on agricultural service delivery was affected by leadership priority and commitment, local policies, local staff capacity, resource allocation and external support. Overlapping and duplication in service delivery roles, weak local capacity, higher conditionality of intergovernmental sectoral fiscal transfer and less priority of local governments in financial resource prioritization are current issues and gaps in agricultural service delivery. The findings suggest the demarcation of the roles and responsibilities between the three tiers of the government, strengthening local capacities and revisiting local governments' institutional arrangement for effective agricultural service delivery under the federal system.

General practitioners working in or alongside the emergency department: the GPED mixed-methods study

BackgroundEmergency care is facing a steadily rising demand. In response, hospitals have implemented new models of care that locate general practitioners in or alongside the emergency department.ObjectivesWe aimed to explore the effects of general practitioners working in or alongside the emergency department on patient care, the primary care and acute hospital team, and the wider system, as well as to determine the differential effects of different service models.DesignThis was a mixed-methods study in three work packages. Work package A classified current models of general practitioners working in or alongside the emergency department in England. We interviewed national and local leaders, staff and patients to identify the hypotheses underpinning these services. Work package B used a retrospective analysis of routinely available data. Outcome measures included waiting times, admission rates, reattendances, mortality and the number of patient attendances. We explored potential cost savings. Work package C was a detailed mixed-methods case study in 10 sites. We collected and synthesised qualitative and quantitative data from non-participant observations, interviews and a workforce survey. Patients and the public were involved throughout the development, delivery and dissemination of the study.ResultsHigh-level goals were shared between national policy-makers and local leads; however, there was disagreement about the anticipated effects. We identified eight domains of influence: performance against the 4-hour target, use of investigations, hospital admissions, patient outcome and experience, service access, workforce recruitment and retention, workforce behaviour and experience, and resource use. General practitioners working in or alongside the emergency department were associated with a very slight reduction in the rate of reattendance within 7 days; however, the clinical significance of this was judged to be negligible. For all other indicators, there was no effect on performance or outcomes. However, there was a substantial degree of heterogeneity in these findings. This is explained by the considerable variation observed in our case study sites, and the sensitivity of service implementation to local factors. The effects on the workforce were complex; they were often positive for emergency department doctors and general practitioners, but less so for nursing staff. The patient-streaming process generated stress and conflict for emergency department nurses and general practitioners. Patients and carers were understanding of general practitioners working in or alongside the emergency department. We found no evidence that staff concerns regarding the potential to create additional demand were justified. Any possible cost savings associated with reduced reattendances were heavily outweighed by the cost of the service.LimitationsThe reliability of our data sources varied and we were unable to complete our quantitative analysis entirely as planned. Participation in interviews and at case study sites was voluntary.ConclusionsService implementation was highly subject to local context and micro-level influences. Key success factors were interprofessional working, staffing and training, streaming, and infrastructure and support.Future workFurther research should study the longer-term effects of these services, clinician attitudes to risk and the implementation of streaming. Additional work should also examine the system effects of national policy initiatives, develop methodologies to support rapid service evaluation and study the relationship between primary and secondary care.Trial registrationThis trial is registered as ISRCTN51780222.FundingThis project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full inHealth and Social Care Delivery Research; Vol. 10, No. 30. See the NIHR Journals Library website for further project information.

ADOPTION OF ICT: A NECESSARY STRATEGY FOR SUSTAINABLE DEVELOPMENT IN THE TWENTY-FIRST CENTURY NIGERIA

The worldwide economic system is increasingly becoming dependent on the ICT system. This article discusses ways in which ICT contributes to several aspects of global sustainability in the areas of Egovernment, E-learning, and E-commerce. The design employed in the study was a descriptive survey. The study was conducted in Aba North local government area of Abia State, Nigeria. Primary data was used for this research work. A sample size of 150 respondents was randomly selected for the study, covering the education sector using the Education Management Board Staff; commerce and industry, using a staff of the ministry; and government/public sector using the Local Government Staff; with each sector having a selected 50 respondents. The instrument used was a 12- item questionnaire on the adoption of ICT as a strategy for sustainable development using E-government, Elearning, and E-commerce as explanatory variables of ICT Adoption. The data collected for the study were analyzed using the appropriate percentage and the responses of the respondents were subjected to a rating scale using their boundary percentages as a basis for their score/rating. The finding revealed that Egovernment enhances the operations of the government and facilitates the effective delivery of government programs’-Learning provides convenient and flexible access to learning; whereas Commerce changed the way goods and services are produced, delivered, sold, and purchased. ICT has led to an ever-growing number of people and businesses connected digitally. Most Nigerians could participate in the International markets from the comfort of their offices and rooms.ICT adoptions have the potential to promote sustainability, productivity, and economic growth through job creation. We, therefore, conclude that ICT Adoption is a veritable tool for sustainable national development in Nigeria. We recommend among others, that Government and other stakeholders should mobilize resources for equipping businesses, education, and governmental sectors with ICT infrastructure and should also embark on Multilevel skill building (capacity improvement).