Public Healthcare Settings Research Articles

Covid-19 hospital mortality using spatial hierarchical models: cohort design with 74,994 registers.

To investigate the relationship between covid-19 hospital mortality and risk factors, innovating by considering contextual and individual factors and spatial dependency and using data from the city of São Paulo, Brazil. The study was performed with a spatial hierarchical retrospective cohort design using secondary data (individuals and contextual data) from hospitalized patients and their geographic unit residences. The study period corresponded to the first year of the pandemic, from February 25, 2020 to February 24, 2021. Mortality was modeled with the Bayesian context, Bernoulli probability distribution, and the integrated nested Laplace approximations. The demographic, distal, medial, and proximal covariates were considered. We found that per capita income, a contextual covariate, was a protective factor (odds ratio: 0.76 [95% credible interval: 0.74-0.78]). After adjusting for income, the other adjustments revealed no differences in spatial dependence. Without income inequality in São Paulo, the spatial risk of death would be close to one in the city. Other factors associated with high covid-19 hospital mortality were male sex, advanced age, comorbidities, ventilation, treatment in public healthcare settings, and experiencing the first covid-19 symptoms between January 24 and February 24, 2021. Other than sex and age differences, geographic income inequality was the main factor responsible for the spatial differences in the risk of covid-19 hospital mortality. Investing in public policies to reduce socioeconomic inequities, infection prevention, and other intersectoral measures should focus on lower per capita income, to control covid-19 hospital mortality.

Fetomaternal Outcome of Referred Obstetric Patients in a Tertiary Centre in North East India: A Cross-sectional Study

Introduction: Referral of patients has improved fetomaternal outcomes in developing countries like India. Identifying high-risk obstetric cases, severe maternal complications, and promptly referring them to a centre equipped with Basic Emergency Obstetric and Newborn Care (BEmONC) helps reduce morbidity and mortality. Aim: To examine the clinical profile of referred obstetric patients admitted to a tertiary care centre and analyse the characteristics of admission, referral pattern, level of delay, and their fetomaternal outcomes. Materials and Methods: A hospital-based observational crosssectional study was conducted from July 1, 2021, to June 30, 2022, at Assam Medical College and Hospital, Dibrugarh in Assam, India. The study included 700 referred obstetric patients from private and public healthcare settings. Variables such as place of referral, referrer (medical officer/self-referral/staff nurse/ specialists), delay in referral, reasons for referral, pregnancy period during referral, diagnosis at admission and referral, availability of proper referral documents, and fetomaternal outcomes such as mode of delivery and gestational age at delivery were assessed. Categorical variables were summarised as proportions and percentages. Results: Out of the total 18,245 obstetric admissions during the study period, approximately 14,500 patients were referred, accounting for 80% of all admissions. Among the 700 study participants, 616 (88%) referrals were from nearby public sectors. A total of 147 (21%) experienced delay due to transportation. 644 (92%) had referral slips, but only 224 (32%) had proper documentation. A number of 322 (46%) were intrapartum referrals. A total of 350 (50%) were primigravida, while 344 (49%) were multigravida. Apart from these 694 pregnant mothers, six referrals were for babieswithout any maternal complications or high risk factors. 112 (16%) referrals were for cases of IUGR and oligohydramnios, and 98 (14%) were preterm referrals. A total number of 276 (47%) deliveries were performed via caesarean section. A total of 35 patients were discharged antepartum, and there were nine maternal deaths. Additionally, 148 neonates required ICU admissions, 225 were preterm, and 558 babies were discharged. Conclusion: Referrals were made for both maternal and foetal causes. The majority of obstetric admissions in our institution were referrals, resulting in an increased delivery rate and a higher trend of caesarean section. The presence of a well-equipped NICU also contributed to the referral pattern.

Knowledge, attitude, and practices toward infection prevention and control among undergraduate pharmacy students in Zambia: findings and implications.

Infection prevention and control (IPC) measures are critical in preventing the risk of acquiring and transmitting nosocomial infections. In Zambia, there is little information concerning IPC practices among pharmacy students who are exposed to potentially infectious areas both in public and private healthcare settings. Therefore, this study assessed the knowledge, attitude, and practices of undergraduate pharmacy students toward infection prevention and control at the University of Zambia. This cross-sectional study was conducted among 290 undergraduate pharmacy students at the University of Zambia using a structured questionnaire from August 2022 to October 2022. Data analysis was performed using SPSS version 25.0, and statistical significance was set at a 95% confidence level. Of the 290 participants, 166(57.2%) were female and the majority were aged between 18 and 23 years. Overall, 252(86.9%) had good knowledge, 167(57.6%) had positive attitudes, and 248(85.5%) had good practices toward IPC measures. These results indicate lower attitude scores compared to knowledge and practices. Having good knowledge of IPC was associated with being a Christian by religion compared to other religions (OR = 5.314, 95% CI: 1.141-24.745). There was no association between sociodemographics and attitude and practice concerning IPC. This study found that pharmacy students had good knowledge, positive attitudes, and good practices toward IPC measures. Consequently, more emphasis is needed to improve the student's knowledge, attitudes, and practices toward IPC, especially in areas where gaps were identified. Additionally, there is a need to improve curricula on IPC measures in the training of pharmacy programs.

Pregnant women's experiences of well-being in high-risk pregnancy: A qualitative study.

Physical changes in high-risk pregnancy (HRP) can lead to changes in mood and social relationships and negative effects on women's well-being. Individuals in different sociocultural contexts have different perceptions of well-being. Yet, there is limited information about perceptions of well-being in HRP. This study aimed to explore the Iranian women's experiences of well-being in HRP. This qualitative study was conducted in 2019-2020 through directed content analysis based on the conceptual framework of well-being in HRP. Participants were 26 women with HRP purposively recruited from public and private healthcare settings in Mashhad, Iran. Face-to-face semistructured interviews were held for data collection until data saturation. Data were analyzed through directed content analysis proposed by Elo and kyngäs (2008) and were managed using the MAXQDA (v. 10) program. Well-being in HRP had seven attributes in the five main dimensions of physical, mental-emotional, social, marital, and spiritual well-being. The seven attributes of well-being in HRP were controlled physical conditions, controlled mood, emotions, and affections, perceived threat, self-efficacy, and competence for multiple role performance, maintained social relationships, meaning seeking and relationship with the Creator, and positive marital relationships. The present study provide an in-depth understanding about well-being in the Iranian women with HRP. It is a complex and multidimensional concept with physical, mental-emotional, social, marital, and spiritual dimensions. Comprehensive multicomponent interventions are needed to promote well-being among women with HRP and designed the guidelines to provide woman-centered care.

Job morale of physicians and dentists in Kazakhstan: a qualitative study

Job morale is thought to be particularly low in Kazakhstan, adversely affecting job motivation, job satisfaction and burnout rates. Previous research suggests that high job morale has a better effect on patient outcomes and care quality. We, therefore, conducted a qualitative study to explore experiences underpinning positive and negative job morale, and to generate potential strategies for improving job morale of physicians and dentists working in public healthcare settings in Kazakhstan prior to the COVID-19 pandemic. Three focus groups containing 23 participants and 30 individual interviews were conducted, evidencing respondents' explanations of what affects job morale, and possible strategies to improve it. Data was synthesised using a thematic analysis. The themes about what influences job morale were: being unfairly rewarded for work; feeling vulnerable and undervalued; poor working styles and practices; and high internal value-based motivation. Various strategies were identified by participants to improve job morale, and these included: ensuring adequate and equitable financial income; improving the current malpractice system; eliminating poor working styles and practices; and creating a shared responsibility for health. The current study has found that despite prevailing threats, job morale amongst physicians and dentists working in public healthcare settings in Astana have been prevented from becoming negative by their strong sense of calling to medicine and the satisfaction of helping patients recover. Emphasising this rather traditional understanding of the role of physicians and dentists may be a way to improve job morale throughout training and practice.

Defining and measuring multimorbidity in primary care in Singapore: Results of an online Delphi study.

Multimorbidity, common in the primary care setting, has diverse implications for both the patient and the healthcare system. However, there is no consensus on the definition of multimorbidity globally. Thus, we aimed to conduct a Delphi study to gain consensus on the definition of multimorbidity, the list and number of chronic conditions used for defining multimorbidity in the Singapore primary care setting. Our Delphi study comprised three rounds of online voting from purposively sampled family physicians in public and private settings. Delphi round 1 included open-ended questions for idea generation. The subsequent two rounds used questions with pre-selected options. Consensus was achieved based on a pre-defined criteria following an iterative process. The response rates for the three rounds were 61.7% (37/60), 86.5% (32/37) and 93.8% (30/32), respectively. Among 40 panellists who responded, 46.0% were 31-40 years old, 64.9% were male and 73.0% were from the public primary healthcare setting. Based on the findings of rounds 1, 2 and 3, consensus on the definition of a chronic condition, multimorbidity and finalised list of chronic conditions were achieved. For a condition to be chronic, it should last for six months or more, be recurrent or persistent, impact patients across multiple domains and require long-term management. The consensus-derived definition of multimorbidity is the presence of three or more chronic conditions from a finalised list of 23 chronic conditions. We anticipate that our findings will inform multimorbidity conceptualisation at the national level, standardise multimorbidity measurement in primary care and facilitate resource allocation for patients with multimorbidity.

Real world data study of prevalence and direct costs related to dengue management in Brazil's private healthcare from 2015 to 2020.

The burden of dengue in Brazil is poorly documented and is based on data from the public health care setting. This study estimated the prevalence and costs of dengue management in the private health care system in Brazil from 2015 to 2020 using a large claims database from Orizon. We selected claims with dengue ICD codes (ICD-10 A90 or A91) from January 2015 to December 2020. Prevalence was estimated based on the population enrolled in health insurance plans in the given year. Costs were adjusted for the inflation up to December 2021 and evaluated by measures of central tendency and dispersion. A total of 63,882 unique beneficiaries were included, with a total of 64,186 dengue cases. The year with the highest prevalence was 2015 (1.6% of patients who used health plans), and there was also an increase in cases in 2016 and 2019. The median cost per hospitalization in 2015 was US$486.17, and in 2020, it reached US$696.72. The median cost of a case seen at an emergency room ranged from US$ 97.78 in 2015 to US$ 118.16 in 2017. The estimated prevalence of dengue in this population of private health-insured patients followed the epidemiological trends of the general population in Brazil, with the highest rates in 2015, 2016, and 2019. The cost of dengue management has increased in the private health care setting over the years.

Time-to-Treatment of Oral Cancer and Potentially Malignant Oral Disorders: Findings in Malaysian Public Healthcare.

This study aims to evaluate the time-to-treatment of oral cancer and potentially malignant oral disorders (PMOD) in a Malaysian public healthcare setting while exploring its contributing factors. It consists of (1) a cross-sectional patient survey to quantify time to seek care and barriers faced, and (2) a retrospective medical record abstraction to determine treatment and management intervals. Time intervals were aggregated and analyzed by their primary contributor-patient, professional, or healthcare system. The average total time-to-treatment of the 104 patients investigated was 167 days (SD = 158). This was predominantly contributed by the patient interval of 120 days (SD = 152). In total, 67.0% of patients delayed their visit to primary healthcare centers because they assumed the lesions were not dangerous or of concern. Additionally, there was a significant difference between patients 'facing' and 'not facing' difficulties to seek care, at 157 vs. 103 days (p = 0.028). System and professional delays were comparably shorter, at 33 days (SD = 20) and 10 days (SD = 15) respectively. Both demonstrated a significant difference between oral cancer and PMOD, at 43 vs. 29 days (p < 0.001) and 5 vs. 17 days (p < 0.001). The findings reiterate the need to reform current initiatives to better promote early lesion recognition by patients and implement strategies for the elimination of their access barriers.

The Importance of Language Delays as an Early Indicator of Subsequent ASD Diagnosis in Public Healthcare Settings

Previous studies have reported that ASD children with more severe symptoms are diagnosed earlier. However, previous studies in community settings have mostly relied on retrospective parental reports without the use of quantitative standardized test scores. Here, we evaluated the association of language, cognitive, and ASD severity standardized scores with the age of diagnosis in 1-6-year-old children diagnosed in a public healthcare setting. The results revealed that language scores were the strongest variable associated with the age of diagnosis, explaining ~ 30% of the variability across children. Indeed, all children diagnosed before 30-months of age exhibited moderate-to-severe language delays. These results further substantiate the prominence of language delay as a highly visible symptom associated with earlier ASD diagnosis in community clinical settings.

Intensive outpatient treatment for PTSD: an open trial combining prolonged exposure therapy, EMDR, and physical activity

ABSTRACT Background: Intensive outpatient treatment could be a promising option for patients with post-traumatic stress disorder (PTSD). Objective: The aim of the study was to test the effectiveness of an eight-day (two-week) intensive treatment for PTSD within a public health care setting (open trial design). Method: Eighty-nine patients were offered the choice between intensive treatment and spaced individual treatment, of which 34 (38.2%) chose the intensive format. Patients were assessed with self-report batteries and interviews at pre-treatment, start of treatment, post-treatment and three-month follow-up. Each day consisted of individual Prolonged Exposure therapy, Eye Movement Desensitization and Reprocessing therapy, group psychoeducation, and physical activity. Therapists rotated between patients. Results: Between 55 and 62% of the patients showed a clinically significant change (recovery) in symptoms of PTSD, and the effect sizes were large (d = 1.38–1.52). Patients also showed reduction in symptoms of depression and anxiety, along with improved well-being and interpersonal functioning. Changes in social and work functioning were more ambiguous. There were no dropouts, attendance was high, and patients were highly satisfied with the treatment. Conclusions: The intensive programme was an attractive and effective treatment option for patients with PTSD.

A qualitative assessment of facility readiness and barriers to the facility-based management of childhood severe acute malnutrition in the public healthcare settings in Bangladesh.

To assess facility readiness and identify barriers to the facility-based management of childhood severe acute malnutrition (SAM) in public healthcare settings. Qualitative methods were applied to assess readiness and identify different perspectives on barriers to the facility-based management of children with SAM. Data collection was done using in-depth interviews, key informant interviews, exit interviews and pre-tested observation tools. Two tertiary care and four district hospitals in Rangpur and Sylhet Divisions of Bangladesh. Healthcare professionals and caregivers of children with SAM. Anthropometric tools, glucometer, medicines, F-75, F-100 and national guidelines for facility-based management of childhood SAM were found unavailable in some of the hospitals. Sitting and sleeping arrangements for the caregivers were absent in all of the chosen facilities. We identified a combination of health system and contextual barriers that inhibited the facility-based management of SAM. The health system barriers include inadequate manpower, rapid turnover of staff, increased workload, lack of training and lack of adherence to management protocol. The major facility barriers were insufficient space and unavailability of required equipment, medicines and foods for hospitalised children with SAM. The reluctance of caregivers to complete the treatment regimen, their insufficient knowledge regarding proper feeding, increased number of attendants and poverty of parents were the principal contextual barriers. The study findings provide insights on barriers that are curbing the facility-based management of SAM and emphasise policy efforts to develop feasible interventions to reduce the barriers and ensure the preparedness of the facilities for effective service delivery.

COVID-19 Vaccine Willingness and Related Factors Among Health Care Workers in 3 Southeast Asian Jurisdictions

COVID-19 vaccine hesitancy is widespread and may lead to refusal or delay of vaccination, eventually reducing the overall vaccination coverage rate and vaccine effectiveness. Willingness to receive COVID-19 vaccination among health care workers (HCWs) is diverse across different jurisdictions. To assess the COVID-19 vaccine willingness among HCWs in 3 Southeast Asian jurisdictions in the context of pandemic severity and vaccination policy. A cross-sectional online survey was conducted among frontline HCWs in Hong Kong, Nepal, and Vietnam from May to November 2021. Eligible participants were nurses and doctors aged 18 and older, working in public or private health care settings on a full-time or part-time basis. The COVID-19 pandemic and vaccination policy. COVID-19 vaccination willingness was defined as HCW willingness toward receiving the COVID-19 vaccine in full course or the first dose of the vaccine, and willingness to take the second dose. Information on sociodemographic characteristics, the history of seasonal influenza vaccination, attitudes toward vaccination, and opinions on strategies associated with vaccination uptake from the study participants. Among the 3396 eligible doctors and nurses who participated in the survey, 2834 (83.4%) were from Hong Kong, 328 (9.7%) were from Nepal, and 234 (6.9%) were from Vietnam. Most respondents were female (76.2% [2589 ]), aged 30 to 39 years (31.2% [1058]), and nurse HCWs (77.6% [2636]); the response rates were 11% (2834 of 25 000) in Hong Kong, 36% (328 of 900) in Nepal, and 13% (234 of 1800) in Vietnam. Overall, the prevalence rate of willingness to take the COVID-19 vaccine was highest in Nepal (95.4% [313 of 328]), followed by Vietnam (90.6% [212 of 234]), and lowest in Hong Kong (54.4% [1542 of 2834]), relating to their different attitudes and opinions toward the COVID-19 vaccination, and the pandemic severity and vaccination policy in the 3 jurisdictions. Doctors were more willing to take COVID-19 vaccination than nurses (odds ratio, 5.28; 95% CI, 3.96-7.04). Older age (odds ratios, 1.39-3.70), male gender (odds ratio, 1.41; 95% CI, 1.11-1.75), higher educational level (odds ratio, 1.48; 95% CI, 1.17-1.87), and having seasonal influenza vaccination uptake history (odds ratio, 2.15; 95% CI, 1.82-2.54) were found to be associated with increased willingness. Choice of vaccination brand with adequate information, immunity passport, time off from work for vaccination and subsidy for travel to inconvenient vaccination centers were considered as strategies to enhance vaccine willingness. In this survey study, vaccination unwillingness existed among HCWs in Southeast Asian regions, especially in Hong Kong. The findings of this study may have utility in the formulation of vaccination promotion strategies such as vaccination incentives. Attitudes toward vaccination in HCWs might be examples for the general population; however, changes over time should be further investigated.

Quantifying the burden of the post-ICU syndrome in South Africa: A scoping review of evidence from the public health sector.

Background The post-ICU syndrome (PICS) comprises unexpected impairments in physical, cognitive, and mental health after intensive care unit (ICU) discharge, and is associated with a diminished health-related quality of life (HRQOL). A Cochrane review recommended more research in this field from low- and middle-income countries. Objectives This review aims to examine the extent and nature of publications in the field of PICS in the South African (SA) public health sector. Findings of available local research are contextualised through comparison with international data. Methods A comprehensive literature search strategy was employed. Inclusion criteria comprised publications enrolling adult patients following admission to SA public hospital ICUs, with the aim to study the main elements of PICS (ICU-acquired neuromuscular weakness, neurocognitive impairment, psychopathology and HRQOL). Results Three studies investigated physical impairment, 1 study psychopathology, and 2 studies HRQOL. Recommended assessment tools were utilised. High rates of attrition were reported. Neuromuscular weakness in shorter-stay patients had recovered at 3 months. Patients who were ventilated for ≥5 days were more likely to be impaired at 6 months. The study on psychopathology reported high morbidity. The HRQOL of survivors was diminished, particularly in patients ventilated for ≥5 days. Conclusion This review found a paucity of literature evaluating PICS in the SA public health sector. The findings mirror those from international studies. Knowledge gaps pertaining to PICS in medical, surgical and HIV-positive patients in SA are evident. No publications on neurocognitive impairment or the co-occurrence of PICS elements were identified. There is considerable scope for further research in this field in SA. Contributions of the study This review identified the available publications investigating the post ICU syndrome (PICS) in the South African public healthcare setting. A small number of ground-breaking studies were found. Knowledge gaps in this field were identified.

Clinical Decision Making using Machine Learning

Abstract: Deaths due to cardiovascular diseases are increasing at an alarming rate. This led to nearly 2.1 million deaths in India in 2015. Heart disease is one of the deadliest causes of death worldwide and has a major impact on the lives of rural people. According to a recent study, cardiovascular disease mortality among rural Indians has surpassed urban Indians. Such numbers are alarming, especially when 68% of India's population lives in rural areas that have poor access to quality healthcare. This paper aims to provide a solution to this problem by introducing a new model*clinical*decision*support system*, abbreviated as CDSS, which*includes machine learning algorithms for the diagnosis of cardiovascular diseases. CDSS is intelligent enough to diagnose a patient's*disease* and help the doctor prescribe the*correct medication, reducing the cost and effort required to prescribe unnecessary treatment. *In this work, we applied correlation-based feature selection (CFS) and a multilayer perceptron classifier on a large heart disease dataset. The dataset used in this study is the "Cleveland Clinic Foundation Heart Disease Dataset" available at the UCI Machine Learning Repository. Our proposed model produced greater accuracy compared to other existing models used in this study. This system can be integrated into a public health care setting to help rural people get a correct, timely and cost-effective diagnosis.

An update of diagnostic efficacy of ultrasound and magnetic resonance imaging in the diagnosis of clinically significant placenta accreta spectrum disorders.

Purpose of reviewSystematic screening and diagnosis of placenta accreta spectrum disorder (PAS) either by ultrasound or magnetic resonance imaging (MRI) would allow referral of high-risk women to specialized multidisciplinary teams. We aimed to report recent findings regarding the diagnostic accuracy of ultrasound and magnetic resonance imaging in the diagnosis of PAS.Recent findingsRecent evidence from the literature shows that both ultrasound and MRI are good tests to identify PAS in high-risk populations. Ultrasound can also be used safely to guide management decisions, concentrating greater resources in patients with the higher risk of clinically significant PAS requiring complex peripartum management. Moreover, there are increasing data showing that routine contingent screening for PAS disorders based on the finding of a placenta implanted low in the uterine cavity and previous uterine surgery is effective in a public healthcare setting. A contingent screening strategy for PAS is feasible if placental location is routinely assessed during routine scans, and may even start from the first trimester of pregnancy.SummaryUltrasound is an effective tool to screen pregnancies at high risk of PAS. In such pregnancies, ultrasound and MRI are effective imaging modalities for guiding management.

Disparities in chronic physical health conditions in sexual and gender minority people using the United States Behavioral Risk Factor Surveillance System

This study analyzed the physical health status of adults who belong to a sexual or gender minority (SGM) population, and whether health inequities correlate with access to quality healthcare. The Centers for Disease Control and Prevention (CDC) 2014–2020 Behavioral Risk Factor Surveillance System (BRFSS) included data for 64,696 adults who identified as gay, lesbian, bisexual, other, and/or transgender and 1,369,681 adults who identified as cisgender and straight. Multivariable logistic regressions of the weighted sample were conducted to examine associations between demographics and health and access outcomes. After accounting for demographic variables, drinking, and smoking behavior, SGM respondents reported poorer physical and mental health, which worsened after the start of the COVID-19 pandemic. SGM respondents had higher odds than non-SGM of having asthma, arthritis, diabetes, kidney disease, hypertension, cardiovascular disease, heart attack, stroke, and chronic obstructive pulmonary disease (COPD), as well as difficulties “see[ing] the doctor because of cost,” particularly after the start of the COVID pandemic. SGM respondents had higher odds of lack of access to healthcare provider, delayed medical care, and issues taking medications due to cost and fewer routine checkups. Thus, the SGM group faced worse health and higher rates of some chronic conditions. This study found a significant relationship with cost barriers attributable to larger societal discrimination regarding SGM individuals, particularly in the workplace. Further research exploring these results is critical, but these findings have identified areas of healthcare inequity to be addressed via preventative health efforts in both public health and primary care settings.

Implementation of clinical guidelines for osteoarthritis together (IMPACT): protocol for a participatory health research approach to implementing high value care

BackgroundThe evidence-based interventions of exercise and education have been strongly recommended as part of prominent clinical guidelines for hip and knee osteoarthritis (OA) for more than ten years. Despite the wealth of strong evidence that exists, implementation in practice is sub-optimal. This paper describes the key methodologies used in the co-design, tailoring, and evaluation of the IMPACT project implementation strategies, to confront this problem across multiple levels (micro, meso, macro) in public and private healthcare settings in Ireland.MethodsUsing a type III hybrid implementation-effectiveness design, a participatory, dynamic and iterative process will be used to tailor and evaluate multi-level implementation strategies using the following stages: 1) Co-design the implementation strategies with key stakeholders using best evidence, a theory-driven implementation framework (Consolidated Framework for Implementation Research), local context and expert consensus; 2) Pilot and evaluate the implementation strategies by training physiotherapists to deliver the evidence-based Good Life with osteoArthritis Denmark (GLA:D®) education and exercise programme using the implementation strategies, and conduct a mixed-methods process evaluation; 3) Adapt the implementation strategies based on implementation process evaluation indicators from stage two. The adapted strategies will be used for scale-up and sustainability in subsequent GLA:D® Ireland training programmes that will be rolled out nationally. Evaluation of effectiveness on patient and cost outcomes will continue up to 12 months post-programme delivery, using an online patient registry and pre-post design.DiscussionThis implementation science project aims to use participatory health research to address a gap in management of OA across public and private healthcare settings. This research has the potential to change practice and promote a policy of exercise and physical activity referral for chronic musculoskeletal disease that utilises community engagement effectively and enacts change ‘together’, with involvement of researchers, decision-makers, clinicians and patients.

Nurse leaders' perceptions of workload and task distribution in public healthcare: A qualitative explorative study.

Unreasonable workload and work-related stress can reduce nurse leaders' job satisfaction and productivity and can increase absence and burnout. Nurse leaders' workload in public healthcare settings is relatively unresearched. The aim of this study was to investigate nurse leaders' perceptions of workload and task distribution with relation to leading work tasks in public healthcare. A qualitative explorative design was used. The data material consisted of texts from interviews with nurse leaders in public healthcare (N=8). The method was inspired by content analysis. The COREQ checklist was used. Informed consent was sought from the participants regarding study participation and the storage and handling of data for research purposes. Six main themes were found: Increased and unreasonable workload, Length of work experience as nurse leader affects perception of workload, Number of staff and staff characteristics affect perception of workload, Versatile and flexible task distribution, Working overtime as a way of managing high workload and Insufficient time for leadership mission. The workload for nurse leaders in a public healthcare setting was perceived to be unreasonable. Common measures for managing high workload included working overtime, delegating work tasks and organising more staff resources in the form of additional staff. How nurse leaders perceive their workload was linked to both the number of staff and staff characteristics. These should both be considered equally important when determining staff levels and measuring nurse leaders' workload. Future research should focus on investigating workload and task distribution from nurses' perspectives. Through this study, greater understanding of workload and the diverse work of nurse leaders in a public healthcare setting has been revealed, which can be used to further develop the framework for nurse leaders' work.

HTA42 The Budget Impact Analysis of Acute Stroke Centre Expansion in Ministry of Health Malaysia

Stroke is the third leading cause of mortality. Acute stroke centre is a specialised, multi-disciplinary and coordinated stroke care that improves stroke care by reducing patients with poor outcomes, death at discharge and functional dependence. This study aimed to assess the budget impact analysis of expanding acute stroke services/centres in the public healthcare setting in Malaysia. The number of hospitalized stroke cases in the next five years is projected from the latest national stroke registry.

Cisplatin-associated ototoxicity: perspectives from a single institution cervical cancer cohort and implications for developing a locally responsive monitoring programme in a public healthcare setting

BackgroundOtotoxicity monitoring is uncommon in South Africa, despite the increased use of ototoxic medication to manage the burden of disease in the country. The successful implementation of such a protocol requires cognisance of contextual realities and multiple dimensions for consideration from both patients and service providers. As part of an ongoing cohort study on cisplatin-associated ototoxicity and efforts to better inform the implementation of such programmes, the perspectives of cervical cancer patients and healthcare workers towards ototoxicity monitoring were assessed.MethodsThis concurrent-triangulation mixed-methods study was conducted at a tertiary hospital in South Africa. Self-reported questionnaires from patients (n = 80) and healthcare personnel comprising clinicians, oncology nurses, pharmacists, and radiotherapists (n = 32), results of audiological evaluations, researcher field notes, and estimated patient and service provider costs contributed to data for this study. Data analysis included descriptive statistics, comparison of test characteristics and deductive thematic analysis.ResultsThe ototoxicity monitoring programme was positively received by the participants, with 90.6% of healthcare personnel and 89% of patients reporting it to be beneficial. The clinicians (76.6%) were identified as the main providers of information on the effects of chemotherapy medication and made the necessary referrals for audiological evaluation. The approximate cost of setting up such a programme included purchase of equipment (US56 700) and the appointment of an audiologist (US 26 250). The approximate costs to patients included transport costs (US$ 38) and the loss of income for the day (US 60), calculated at the minimum wage per hour, if employed. Creative appointment scheduling, easy facility access and detailed locally comprehensible couselling improved patient compliance to the programme. Whilst the sequential use of American Speech-Language-Hearing Association (ASHA) and National Cancer Institute Common Terminology Criteria for Adverse Events (NCI-CTCAE) criteria aided in an evidence-informed approach to aural rehabilitation, DPOAEs and speech discrimination displayed low sensitivity (range 1.45% – 22.39%) but high specificity (range 77.78% – 100%) when identifying ototoxic change.ConclusionThis novel study, through a ‘real-world’ experience, has revealed that an ototoxicity monitoring programme is feasible in South Africa, through meaningful engagements with- and considerations from- patients and service providers regarding planning, delineation of responsibilities and cost implications. The findings can potentially serve as a roadmap for other limited resource environments.