Lower Quality Of Care Research Articles

Assessment of the quality of antenatal care in Mozambique

ObjectiveTo assess the quality of antenatal care and its covariates among postpartum women in Mozambique. DesignCross-sectional study. SettingThe study was undertaken either at the maternity hospital or at home, in Mozambique, in 2019. ParticipantsA total of 393 women aged 18 to 49 years were interviewed immediately after giving birth. MeasurementsThe quality of antenatal care was analysed based on the guidelines of the Ministry of Health of Mozambique: antenatal appointment in the first 16 weeks of gestation, 4 or more antenatal appointments, at least one laboratory test, at least 4 or more clinical-obstetric procedures, 3 doses of the prophylactic intermittent treatment for malaria, 2 doses of the tetanus vaccine, and counselling related to general health care. Women who reported all of these situations were classified as having had quality antenatal care. FindingsAll women reported at least one antenatal care visit, but only 13.0% were classified as having had quality antenatal care. Women who underwent antenatal care in previous pregnancies (aOR=4,28; 95% CI=1,45–12,62) and whose current pregnancy was planned (aOR=2,51; 95% CI=1,11–5,68) were more likely to have quality antenatal care than those who had never had access to antenatal care in previous pregnancies and those who currently had an unplanned pregnancy. It was observed that the criteria recommended by the Ministry of Health were not followed during antenatal care, especially regarding the gestational age at the beginning of antenatal care, the minimum number of consultations, performing blood tests (complete blood count, blood glucose, blood typing and Rh factor) and guidance on signs of risk in pregnancy and childbirth. Key conclusionsIn general, the criteria recommended for quality antenatal care are not incorporated into clinical practice in Mozambique. Implications for practiceWhile quality antenatal care is essential to reduce maternal morbidity and mortality, many sub-Saharan countries still have low-quality antenatal care services, which is one of the reasons why these countries have the highest maternal mortality rates worldwide.

Abstract C127: Mental health and quality of care levels associated with race and socioeconomic status among cancer patients

Abstract Mental health and quality of cancer care are factors that significantly impact a cancer patient’s health outcomes. It is imperative that all patients, regardless of race or socio-economic status (SES), have equitable opportunities for optimal cancer survival. Recent reports suggest, African American (AA) cancer patients have the highest cancer mortality rates and lowest survival rates of any racial and ethnic group in the United States (U.S.). (cite) These alarming statistics, attributed in part to disparities in healthcare, can be linked to individual level stressors, modifiable risk factors, and structural characteristics of the health system. Recent studies suggest, AA’s and individuals of low SES in the U.S., are more likely to suffer disproportionately from social determinants of health (SDOH) that may contribute to chronic stress over the lifespan. Chronic stress is shown to have a negative impact on the mental health of a patient which can potentially contribute to progression of disease and effectiveness of cancer treatments. Quality of cancer care may even contribute to lower or higher rates of cancer patient stress. The complex interplay of mental health and quality of cancer care with race and SES can have a significant impact on the health outcomes of cancer patients. Methods Data for this study will be obtained from the National Cancer Institute’s Health Informational National Trends Survey (HINTS 5, CYCLE 4), a nationally representative cross sectional survey of American adults using telephone and postal mail. Secondary analysis of the dataset will be conducted using respondents. Participant characteristics and behaviors will be examined using weighted descriptive statistics. Bivariate chi square analyses will be conducted to examine the association between each independent variable (gender, race/ethnicity, age, level of education, level of income, and can afford treatment without it effecting finances) and the dependent variable as stress and distress scores and quality of care Multivariable logistic regression analyses will be used to estimate adjusted odds ratios (AORs) and 95% confidence intervals (95% Cis) to determine whether race and socioeconomic status factors affect stress, distress scores, and quality of care. Results We will report findings relative to African American cancer patients of the same socio-economic status as White cancer patients and the association with lower quality of care and higher stress scores. Additional we will present findings relative to the association of African American cancer patients of lower socio-economic status with have higher stress scores and lower quality of care than African Americans of higher socio-economic status. Lastly, we will present data on the association of financial toxicity, race, SES, and stress score and quality of cancer care. Conclusion It is anticipated the findings from this study will inform future intervention strategies to address social determinants of health in clinical and non-clinical settings. Citation Format: Jamirah Y. Chevrin, Brian Rivers. Mental health and quality of care levels associated with race and socioeconomic status among cancer patients [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr C127.

The Early Impact of the COVID-19 Pandemic on Hospital Finances.

The COVID-19 pandemic has caused both short- and long-term impacts on every aspect of society. Hospitals are among the most critical frontliners and have had to continually navigate the challenges caused by the pandemic. In this study, we examined hospitals' financial performance following the onset of the pandemic. We used data from the Centers for Medicare & Medicaid Services Healthcare Cost Report Information System. The study sample included all general acute care and critical access hospitals that receive Medicare payments. The primary outcomes included operating margins, net patient revenues, operating expenses, and uncompensated care costs. We tested for average changes from 2019 to 2020 in hospitals' financial outcomes. We also tested for changes in financial outcomes across samples stratified by hospital characteristics: ownership type (investor-owned, nonprofit, and public), Medicaid disproportionate share hospital status, rural status, county uninsured rate quartile, and Medicaid expansion status. Our sample consisted of a balanced panel of 4,059 hospitals (8,118 observations) with data spanning 2019 and 2020. Across the full sample of hospitals, operating margins declined by an average of 5.3 percentage points between 2019 and 2020, equating to a 130% reduction from 2019 levels. Underlying these margin declines, net patient revenues declined by 3.2% on average, while operating expenses increased by 1.5%. We observed no changes in uncompensated care costs despite the large number of job losses that accompanied the pandemic. When stratifying the analysis by hospital characteristics, differences were observed across ownership types. Notably, investor-owned facilities were less affected financially than nonprofit and public hospitals. Although safety-net and rural hospitals generally fared no worse than their non-safety-net and nonrural counterparts, hospitals located in Medicaid expansion states experienced steeper declines in operating margins relative to hospitals located in nonexpansion states, driven by larger relative declines in patient revenues. The operating margin declines we observed can be attributed to supply-chain issues, persistent labor shortages, and suspension of elective services. The Affordable Care Act reforms in health insurance markets likely helped to insulate hospitals from increases in uncompensated care costs. In the shifting context of the pandemic, it is important to understand hospitals' financial performance so that measures can be taken to address further financial distress that may eventually lead to increased consolidation, hospital closures, and lower quality of care. Our findings stress the need for targeted responses that are tailored to underlying hospital characteristics. Temporary and targeted increases in inpatient and outpatient service prices can help offset revenue losses from the deferment of nonurgent care. Other policies can address the ongoing workforce challenges and supply-chain issues.

Post-COVID19 strategies to support the health care interactions of U.S. Mexican immigrants and return migrants with the Mexican health system

BackgroundMexican migrants in the United States (U.S.) are twice more likely to underutilize health care and to experience low quality of care compared to the U.S.-born population. Current and former Mexican migrants in the U.S have used health services in Mexico due to lower cost, perceived quality, cultural familiarity, and the geographic proximity of the two countries. ObjectiveThis study aims to characterize the different health care interactions of current and former U.S. Mexican migrants with public and private health care organizations of the Mexican health system and to identify strategies to improve health care interactions post-COVID19. MethodsWe use a typology of cross-border patient mobility to analyze the facilitators and barriers to improve the health care interactions of current and former U.S. Mexican migrants with the Mexican health system. Our policy analysis framework examines how an outcome can be achieved by various configurations or combinations of independent variables. The main outcome variable is the improvement of health care interactions of U.S. Mexican migrants and return migrants with different government agencies and public and private health care providers in the Mexican health system. The main explanatory variables are availability, affordability, familiarity, perceived quality of health care and type of health coverage. FindingsAs the Mexican health system emerges from the COVID19 pandemic, new strategies to integrate current and former U.S. Mexican migrants to the Mexican health system could be considered such as the expansion of telehealth services, a regulatory framework for health services used by transnational patients, making enrollment procedures more flexible for return migrants and guiding return migrants as they reintegrate to the Mexican health system. ConclusionsThe health care interactions of U.S. Mexican migrants with the Mexican health system are likely to increase in the upcoming decades due to population ageing. Regulatory improvements and programs that address the unique needs of U.S. Mexican migrants and return migrants could substantially improve their health care interactions with the Mexican health system.

Telemedicine utilization and perceived quality of virtual care among pregnant and postpartum women during the COVID-19 pandemic

Introduction The aim of this research was to examine the association between perceived quality of care during the COVID-19 pandemic and the modality of maternity care visits, virtual or in-person. Methods This study utilized an online nationwide survey about experiences in prenatal and postpartum care between 18 April and 6 August 2020. Perceived quality of care was categorized into worse care, better, or the same care as compared to before the pandemic. Barriers were categorized into five groups: (1) concern for the privacy of health information, (2) not having a private or quiet place, (3) lack of physical exam or measurements, (4) quality of care, and (5) technology issues. Data analyses included bivariate analyses and multivariate logistic regression. Results The majority (75.3%) of modified visits utilized telemedicine. Over half of the women took at-home measurements and the majority were successful. Barriers to care included a lack of a quiet or private space to conduct their visit. Women expressed concerns about a lack of measurements and a lower quality of care. Women who received telemedicine visits perceived worse care as compared to women who received in-person care visits (OR = 5.62; 95% CI 5.01–6.31). Discussion Previous studies have shown that pregnant patients are generally satisfied with virtual care during the pandemic. This study provides insight from a large nationwide sample of women and geographic variation in satisfaction and perceived quality. These findings highlight barriers and potential solutions to improving patients’ perceived quality of virtual maternity care, and thus future uptake of high-quality, virtual care.

Using Resident-Sensitive Quality Measures Derived From Electronic Health Record Data to Assess Residents' Performance in Pediatric Emergency Medicine.

Traditional quality metrics do not adequately represent the clinical work done by residents and, thus, cannot be used to link residency training to health care quality. This study aimed to determine whether electronic health record (EHR) data can be used to meaningfully assess residents' clinical performance in pediatric emergency medicine using resident-sensitive quality measures (RSQMs). EHR data for asthma and bronchiolitis RSQMs from Cincinnati Children's Hospital Medical Center, a quaternary children's hospital, between July 1, 2017, and June 30, 2019, were analyzed by ranking residents based on composite scores calculated using raw, unadjusted, and case-mix adjusted latent score models, with lower percentiles indicating a lower quality of care and performance. Reliability and associations between the scores produced by the 3 scoring models were compared. Resident and patient characteristics associated with performance in the highest and lowest tertiles and changes in residents' rank after case-mix adjustments were also identified. 274 residents and 1,891 individual encounters of bronchiolitis patients aged 0-1 as well as 270 residents and 1,752 individual encounters of asthmatic patients aged 2-21 were included in the analysis. The minimum reliability requirement to create a composite score was met for asthma data (α = 0.77), but not bronchiolitis (α = 0.17). The asthma composite scores showed high correlations ( r = 0.90-0.99) between raw, latent, and adjusted composite scores. After case-mix adjustments, residents' absolute percentile rank shifted on average 10 percentiles. Residents who dropped by 10 or more percentiles were likely to be more junior, saw fewer patients, cared for less acute and younger patients, or had patients with a longer emergency department stay. For some clinical areas, it is possible to use EHR data, adjusted for patient complexity, to meaningfully assess residents' clinical performance and identify opportunities for quality improvement.

The Impact of Implicit Bias on Black and Latinx Students.

The Impact of Implicit Bias on Black and Latinx Students.

Capacity building among nursing and midwifery professional associations in East Africa

ABSTRACT Background Despite improvements in educational opportunities, policy changes, and pay raises in the nursing and midwifery professions in East Africa, poor working conditions, few professional development opportunities, and a general lack of respect for these professions predominate. These issues contribute to a low quality of care among a population with a high burden of communicable diseases. Health professional associations may help to address these challenges by providing a voice for nurses and midwives. Objective This study evaluated the impact of a 5-year programme focused on strengthening nurses’ and midwives’ professional associations in East Africa. Methods This study used a mixed methods design. Quantitative, cross-sectional descriptive data were captured via surveys (n = 1,266) distributed to association members. In-depth interviews (n = 65) were used to obtain qualitative data and complement the survey responses. Quantitative and qualitative data collection occurred concurrently. The results were compared to assess the impact of the programme across Uganda, Kenya, and Tanzania. Results The programme successfully built capacity in four of five organisational capacity areas: resource mobilisation, financial management, strategy, and monitoring and evaluation. Marketing and communications, the fifth targeted area, did not show improvement. Capacity in both research and service delivery was also improved, despite the programme not providing training in these areas. In addition, collaboration among associations and their members was improved. Conclusion These results support existing evidence on the impact of capacity building among professional nursing associations and coincide with the World Health Organization’s objectives for nursing. Future capacity building programmes should consider replicating the successful activities from this programme and investigate ways to reach more rural branches and provide tailored content. This study contributes to a small but growing body of knowledge that supports capacity building among the African health workforce.

Differences in Quality of Care of Family Planning Services Received by Age and Contraceptive Continuation Among Young Mothers in India

PurposeYouth face barriers that affect their use of family planning (FP) services, including low quality of care and provider bias. Although young women have the highest unmet need for FP in India, little is known about the effect of age on quality of care received. Additionally, although youth have higher contraceptive discontinuation than older women, the factors associated with continuation, including the effect of quality of care, are not well known. This study aims to assess differences in quality of care received by young mothers aged 15–24 and mothers aged 25–48, and to examine factors associated with modern contraceptive continuation 6 months after initiation among young mothers. MethodsData come from a 12-month longitudinal study of married reversible contraceptive users in India. Multinomial logistic regression was conducted to examine adjusted associations of age and reported receipt of low, medium, or high quality of care. Logistic regression was used to assess factors associated with modern contraceptive continuation after 6 months. ResultsResults showed that young mothers were less likely to receive high quality of care than older mothers, and that among young mothers, motivation to prevent pregnancy was significantly associated with continued use after 6 months. DiscussionAs India aims to improve quality of care and increase access to services for youth, special attention should be paid to care received by young mothers, as well as options to support them in continuing to use contraceptive methods as long as they desire to prevent pregnancy.

Trends in facility-based childbirth and barriers to care at a birth center and community hospital in rural Chiapas, Mexico: A mixed-methods study

ObjectiveTo assess trends in childbirth at a hospital-birth center among women living in Compañeros En Salud (CES)-affiliated communities in Chiapas, Mexico and explore barriers to childbirth care. Our hypothesis was that despite interventions to support and incentivize childbirth at the hospital-birth center, the proportion of births at the hospital-birth center among women from Compañeros En Salud-affiliated communities has not significantly changed after two years. We suspected that this may be due to structural factors impacting access to care and/or perceptions of care impacting desire to deliver at the birth center. DesignThis explanatory mixed-methods study included a retrospective Compañeros En Salud maternal health census review followed by quantitative surveys and semi-structured qualitative interviews. Participants and SettingParticipants were women living in municipalities in the mountainous Sierra Madre region of Chiapas, Mexico who received prenatal care in one of 10 community clinics served by Compañeros En Salud. Participants were recruited if they gave birth anywhere other than the primary-level rural hospital and adjacent birth center supported by Compañeros En Salud, either at home or at other facilities. MeasurementsWe compared rates of birth at the hospital-birth center, other health facilities, and at home from 2017-2018. We conducted surveys and interviews with women who gave birth between January 2017-July 2018 at home or at facilities other than the hospital-birth center to understand perceptions of care and decision-making surrounding childbirth location. FindingsWe found no significant difference in rates of overall number of women birthing at the hospital-birth center from Compañeros En Salud-affiliated communities between 2017 and 2018 (p=0.36). Analysis of 158 surveys revealed distance (30.4%), time (27.8%), and costs (25.9%) as reasons for not birthing at the hospital-birth center. From 27 interviews, negative perceptions and experiences of the hospital included low-quality and disrespectful care, low threshold for medical interventions, and harm and suffering. Partners or family members influenced most decisions about childbirth location. Key ConclusionsInterventions to minimize logistical barriers may not be sufficient to overcome distance and perceptions of low-quality, disrespectful care. Implications for PracticeBetter understanding of complex decision-making around childbirth will guide Compañeros En Salud in developing interventions to further meet the needs and preferences of birthing women in rural Chiapas.

Resident racial and ethnic composition, neighborhood-level socioeconomic status, and COVID-19 infections in California SNFs.

In California, >29,000 residents in skilled nursing facility (SNFs) were diagnosed with novel coronavirus disease 2019 (COVID-19) between March 2020 and November 2020. Prior research suggests that SNFs serving racially and ethnically minoritized residents often have fewer resources and lower quality of care. We performed a cross-sectional analysis of COVID-19 incidence among residents in California SNFs, assessing the association of SNF-level racial and ethnic compositions and facility- and neighborhood-level (census tract- and county-level) indicators of socioeconomic status (SES). SNFs were grouped based on racial and ethnic composition using data from the Centers for Medicare and Medicaid Services; categories included SNFs with ≥88% White residents, SNFs with ≥32% Black or Latinx residents, SNFs with ≥32% Asian residents, or SNFs not serving a high proportion of any racial and ethnic composition (mixed). SNF resident-level COVID-19 infection data were obtained from the National Healthcare Safety Network from May 25, 2020 to August 16, 2020. Multilevel mixed-effects negative binomial regressions were used to estimate incidence rate ratios (IRR) for confirmed COVID-19 infections among residents. Among 971 SNFs included in our sample, 119 (12.3%) had ≥88% White residents; 215 (22.1%) had ≥32% Black or Latinx residents; 78 (8.0%) had ≥32% Asian residents; and 559 (57.6%) were racially and ethnically mixed. After adjusting for confounders, SNFs with ≥32% Black or Latinx residents (IRR=2.40 [95% CI=1.56, 3.68]) and SNFs with mixed racial and ethnic composition (IRR=2.12 [95% CI=1.49, 3.03]) both had higher COVID-19 incidence rates than SNFs with ≥88% White residents. COVID-19 incidence rates were also found to be higher in SNFs with low SES neighborhoods compared to those in high SES neighborhoods. Public health personnel should consider SNF- and neighborhood-level factors when identifying facilities to prioritize for COVID-19 outbreak prevention and control.

Relationships among illness understanding, information preferences, and adherence to oral anticancer therapy.

250 Background: Patients prescribed oral anticancer therapy receive less support for adherence and symptom monitoring from oncologists compared to infusional cancer therapy, which can result in lower quality care and worse disease outcomes. Identifying factors related to adherence can guide efforts to develop patient-centered interventions. The goal of this analysis was to examine associations among patients’ illness understanding, information preferences, and oral anticancer therapy adherence. Methods: We conducted a secondary analysis of a randomized trial testing the efficacy of a mobile application to improve assessment of symptoms and treatment adherence. Eligible patients included adults diagnosed with cancer prescribed oral anticancer therapy. To assess adherence, participants stored their medication for three months in a Medication Event Monitoring System (MEMS) bottle that electronically records the date and time the bottle is opened. At baseline, participants completed the Prognosis and Treatment Perceptions Questionnaire, which assesses patients’ illness understanding and information preferences in communicating with oncologists. We conducted linear regression to examine associations among patients’ illness understanding, information preferences, and medication adherence. Results: The study included 181 patients prescribed oral anticancer therapy (Mean age = 53.30 years; 53.6% female; 87.8% white). The most common cancer types were hematologic (33.1%), lung (18.2%), and breast (14.4%) malignancies. Two-thirds (66.9%) were prescribed oral targeted therapies, and 35.5% self-identified as terminally ill. Controlling for intervention effects, patients who reported wanting as many details as possible related to their cancer and treatment had higher MEMS adherence over the three-month study period (B = 12.84, 95%CI: 3.65, 22.03, p =.006) versus those who preferred to know fewer details. Also, patients who reported that it was extremely important for them to know their prognosis had higher adherence (B = 9.93, 95%CI: 1.73, 18.13, p =.018) versus those who rated knowing about prognosis as less important, though this relationship was moderated by illness understanding. Specifically, in the subgroup of patients reporting that they were not terminally ill, the association between wanting to know about prognosis and MEMS adherence remained significant (p =.006), which was not the case for patients identifying as terminally ill (p =.776). Conclusions: In this sample, patients’ desire for information about their cancer and prognosis was strongly associated with higher adherence to oral anticancer therapy over the following three months. Yet, this association may be stronger among those who do not identify as terminally ill. Targeted interventions that support patients who prefer fewer details about their illness and prognosis may improve medication adherence.

How to Perform Quality Improvement Projects.

Safety and efficiency remain salient concerns for the US health-care system, especially in the face of growing health-care costs and morbidity from low-quality care. Current estimates suggest that more than 20% of health-care costs in the United States represent waste and low-value care, presenting numerous improvement opportunities. Although current guidelines and standards aim to address these problems, system processes and clinician behavior must also change to fill care gaps in the health-care system. Quality improvement (QI) is a systematic approach to safety or value gaps in care that uses data measured over time and then makes sequential, small changes to achieve a measurable aim. The Model for Improvement provides a general framework for approaching QI. In this review article, we describe the general approach to conducting QI studies in the health-care setting using the Model for Improvement as a guide, including identifying a problem, performing testing, measuring change, and implementing successful ideas. We also summarize common issues that QI teams face and should consider if sharing their QI work through publication. By following a systematic approach, QI teams can develop and implement interventions aimed at addressing gaps in care, thereby improving overall health-care value and safety for their patients.

Comparing two advance care planning conversation activities to motivate advance directive completion in underserved communities across the USA: The Project Talk Trial study protocol for a cluster, randomized controlled trial

BackgroundAdvance care planning (ACP) is a process involving conversations between patients, loved ones, and healthcare providers that consider patient preferences for the types of medical therapies received at the end of life. Underserved populations, including Black, Hispanic, rural, and low-income communities are less likely to engage in ACP than other communities, a health inequity that results in lower-quality care and reduced hospice utilization. The purpose of this trial is to compare efficacy of two interventions intended to motivate ACP (particularly advance directive completion) for those living in underserved communities.MethodsThis 3-armed cluster, randomized controlled mixed methods design is being conducted in 75 community venues in underserved communities across the USA. The goal of the trial is to compare the efficacy of two interventions at motivating ACP. Arm 1 uses an end-of-life conversation game (Hello); Arm 2 uses a nationally utilized workshop format for ACP conversations (The Conversation Project); and Arm 3 uses an attention control game (TableTopics). Events are held in partnership with 75 local community-based host organizations and will involve 1500 participants (n=20 per event). The primary outcome is completion of a visually verified advance directive at 6 months post-event. Primary analyses compare efficacy of each intervention to each other and the control arm. Secondary mixed methods outcomes include (a) other ACP behaviors and engagement; (b) communication quality; (c) impact of sociocultural environment on ACP (via qualitative interviews); and (d) implementation and sustainability. Subgroup analyses examine outcomes for Black, Hispanic, and rural groups in particular.DiscussionThis trial will add to the evidence base behind various conversational ACP interventions, examine potential mechanisms of action for such interventions, and provide qualitative data to better understand the sociocultural environment of how community-based ACP interventions are experienced by underserved populations. Results will also provide important data for future researchers to learn whether visual verification of advance directives is necessary or whether reliance on self-reported outcomes is of comparable value. Data from this study will inform ways to effectively motivate underserved communities to participate in advance care planning.Trial registrationClinicalTrials.gov NCT04612738. Registered on October 12, 2020. All information from the WHO Trial Registration Data Set can be found within the protocol.

37 Inequities Among Emergency Department Hallway Utilization

Emergency department (ED) crowding is a constant and relentless operational challenge facing hospitals across the country. In response to limited capacity, many EDs increasingly care for patients in hallways to provide timely access to ED evaluation. However, hallway placement can also lead to lower patient satisfaction and lower quality of care. We sought to explore social risk factors and ED operations features that may be associated with the hallway placement decision.

How colleges should lead on climate.

How colleges should lead on climate.

The impact of the COVID-19 pandemic on perinatal loss among Italian couples: A mixed-method study.

BackgroundPerinatal bereavement is an event that greatly impacts the emotional, psychological, and psychosocial aspects of those who want to have a child.ObjectivesSince there are few studies on the psychological impact of the COVID-19 pandemic on couples grieving for perinatal loss, this research aimed to survey this experience.ParticipantsBetween 2020 and 2021, in Italian provinces highly affected by the COVID-19 pandemic, 21 parents participated: 16 mothers (76%; mean age 36.2; SD: 3.1) and 5 fathers (24%; mean age 40.2; SD: 3.4), among which there were 4 couples.MethodsA mixed-method design was used through self-report questionnaires and in-depth interviews. Accompanied by a sociodemographic form, the following questionnaires were administered: Prolonged Grief-13, the Parental Assessment of Paternal Affectivity (PAPA) (to fathers), the Parental Assessment of Maternal Affectivity (PAMA) (to mothers), the Dyadic Adjustment Scale short version, the Daily Spiritual Experiences Scale, and the Impact of Event Scale-Revised. The texts obtained through the in-depth interviews underwent thematic analysis.ResultsFifty per cent of participants suffered from Post-Traumatic Stress Disorders (PTSD) symptoms and 20% suffered from relational dyadic stress. Four areas of thematic prevalence emerged: psychological complexity of bereavement, the impact of the COVID-19, disenfranchisement vs. support, and spirituality and contact with the lost child. Participants interpreted their distress as related to inadequate access to healthcare services, and perceiving the pandemic restrictions to be responsible for less support and lower quality of care. Furthermore, they needed psychological help, and most of them were unable to access this service. Spirituality/religiosity did not help, while contact with the fetus and burial did.ConclusionIt is important to implement psychological services in obstetrics departments to offer adequate support, even in pandemic situations.

Influence of a quality improvement intervention on rehabilitation outcomes of children (6–24 months) with acute malnutrition: a retrospective study in rural Angola

BackgroundDefaulting is the most frequent cause of Community Management of Acute Malnutrition (CMAM) program failure. Lack of community sensitization, financial/opportunity costs and low quality of care have been recognized as the main driving factors for default in malnutrition programs. The present study aimed to evaluate if a logistic reorganization (generic outpatient department, OPD vs dedicated clinic, NRU) and a change in management (dedicated vs non dedicated staff) of the follow-up of children between 6 and 24 months of age with acute malnutrition, can reduce the default, relapse and readmission rate and increase the recovery rate.MethodsRetrospective observational study on the impact of quality improvement interventions on rehabilitation outcomes of children (6–24 months) with acute malnutrition, admitted at the Catholic Mission Hospital of Chiulo (Angola) from January 2018 to February 2020. Main outcome measures were recovery rate, the default rate, the relapse rate, and the readmission rate.ResultsThe intervention was associated with a decrease in the default rate from 89 to 76% (p = 0.02). Recovery rate was 69% in OPD and 88% in NRU (p = 0.25). Relapse rate was nil.ConclusionsThe present study supports the hypothesis that an improvement in quality of care can positively influence the rehabilitation outcomes of malnourished children. Further studies are needed to identify children at risk of low adherence to follow-up visits to increase the effectiveness of rehabilitation programs.

Assessing the quality of tuberculosis care using routine surveillance data: a process evaluation employing the Zero TB Indicator Framework in Mongolia

ObjectivesTo evaluate the feasibility of the Zero TB Indicator Framework as a tool for assessing the quality of tuberculosis (TB) case-finding, treatment and prevention services in Mongolia.SettingPrimary health centres, TB...

Inequalities in the geographical distribution and workload of obstetrics and gynaecology specialists by gender in Turkey.

Women often have a preference for female obstetrics and gynaecology specialists (ob/gyns). Following the policy allowing physician selection by patients in Turkey, distribution of ob/gyns by gender across provinces has been an important indicator of access to healthcare. To analyse ob/gyns distribution by gender across provinces in Turkey, with emphasis on the relationship with conservativeness of the province and resulting physician workload. We measured the number of male and female ob/gyns by province in 2016 and the number of outpatient visits and deliveries performed by male and female ob/gyns in 2015. Pearson and Spearman correlation of the female ratio with votes for conservative parties was used to assess the distribution of ob/gyns. We then analysed the correlation with resulting workload of female ob/gyns and ran linear regressions of these variables controlling the number of ob/gyns in a province. More conservative provinces, measured by the vote share for conservative political parties, have a higher ratio of female ob/gyns. Linear regression showed that a 1 percentage point (pp) increase in the vote share corresponded to a 0.69 pp increase in female ratio. For workload, a 1 pp higher female ratio resulted in a decrease in workload, measured as outpatient visits per female ob/gyn divided by that per male ob/gyn, by 0.014. Conservative provinces have more female ob/gyns, but other provinces compensate for that with higher female ob/gyn workload. High workload may have adverse health effects and result in lower quality of care.