Health System Stakeholders Research Articles

What Matters in Cancer Survivorship Research? A Suite of Stakeholder-Relevant Outcomes.

The outcomes assessed in cancer survivorship research do not always match the outcomes that survivors and health system stakeholders identify as most important in the post-treatment follow-up period. This study sought to identify stakeholder-relevant outcomes pertinent to post-treatment follow-up care interventions. We conducted a descriptive qualitative study using semi-structured telephone interviews with stakeholders (survivors, family/friend caregivers, oncology providers, primary care providers, and cancer system decision-/policy-makers) across Canada. Data analysis involved coding, grouping, detailing, and comparing the data by using the techniques commonly employed in descriptive qualitative research. Forty-four participants took part in this study: 11 survivors, seven family/friend caregivers, 18 health care providers, and eight decision-makers. Thirteen stakeholder-relevant outcomes were identified across participants and categorized into five outcome domains: psychosocial, physical, economic, informational, and patterns and quality of care. In the psychosocial domain, one’s reintegration after cancer treatment was described by all stakeholder groups as one of the most important challenges faced by survivors and identified as a priority outcome to address in future research. The outcomes identified in this study provide a succinct suite of stakeholder-relevant outcomes, common across cancer types and populations, that should be used in future research on cancer survivorship care.

Thematic Analysis of Challenges of Care Coordination for Underinsured and Uninsured Cancer Survivors With Chronic Conditions

Although a majority of underinsured and uninsured patients with cancer have multiple comorbidities, many lack consistent connections with a primary care team to manage chronic conditions during and after cancer treatment. This presents a major challenge to delivering high-quality comprehensive and coordinated care. To describe challenges and opportunities for coordinating care in an integrated safety-net system for patients with both cancer and other chronic conditions. This multimodal qualitative study was conducted from May 2016 to July 2019 at a county-funded, vertically integrated safety-net health system including ambulatory oncology, urgent care, primary care, and specialty care. Participants were 93 health system stakeholders (clinicians, leaders, clinical, and administrative staff) strategically and snowball sampled for semistructured interviews and observation during meetings and daily processes of care. Data collection and analysis were conducted iteratively using a grounded theory approach, followed by systematic thematic analysis to organize data, review, and interpret comprehensive findings. Data were analyzed from March 2019 to March 2020. Multilevel factors associated with experiences of coordinating care for patients with cancer and chronic conditions among oncology and primary care stakeholders. Among interviews and observation of 93 health system stakeholders, system-level factors identified as being associated with care coordination included challenges to accessing primary care, lack of communication between oncology and primary care clinicians, and leadership awareness of care coordination challenges. Clinician-level factors included unclear role delineation and lack of clinician knowledge and preparedness to manage the effects of cancer and chronic conditions. Primary care may play a critical role in delivering coordinated care for patients with cancer and chronic diseases. This study's findings suggest a need for care delivery strategies that bridge oncology and primary care by enhancing communication, better delineating roles and responsibilities across care teams, and improving clinician knowledge and preparedness to care for patients with cancer and chronic conditions. Expanding timely access to primary care is also key, albeit challenging in resource-limited safety-net settings.

Overcoming the challenges of community-engaged emergency referrals in a rural district of Pakistan

A functional referral system for addressing maternal and child health issues requires coordinated efforts by health system stakeholders and community. Using Rural Health Program (RHP) Thatta as platform provided by an academic institution, district health system stakeholders and community of Mirpur Sakro taluka of Thatta were engaged to strengthen the emergency referral system for maternal and child health emergencies through active community engagement. Through combined consultation, referral system plan for maternal and child health emergencies was developed. Community volunteers from each village liaised for transportation, referring patients to health facilities and maintaining referral documentation. An ambulance service under contract with health department and private transporters were taken on-board to facilitate patients’ transportation. Community’s experiences of referral system were assessed through qualitative in-depth interviews. Patients’ experiences of referral system improved but faced structural challenges including out of pocket transport expenses, direct self-referrals, Continuous...

Overcoming the challenges of community-engaged emergency referrals in a rural district of Pakistan.

A functional referral system for addressing health emergencies requires coordinated efforts by health system's stakeholders and the community. Using the Rural Health Programme (RHP) Thatta as a platform provided by an academic institution, district health system stakeholders and the community of Mirpur Sakro, taluka of Thatta, were engaged to strengthen the referral system for health emergencies through active community engagement. Through consultations with stakeholders, a referral system plan was developed with community volunteers from each village as focal persons for transportation, referring patients to health facilities and maintaining referral documentation. The stakeholders' experience and perceptions about the referral system were assessed through qualitative in-depth interviews. Patients' experiences of referral system improved with enhanced transport availability, but they faced structural challenges, including out of pocket transport expenses, weak back-referral links, lack of trust between the community and healthcare providers and poor availability of medicines.

Management of chronic lung diseases in Sudan and Tanzania: how ready are the country health systems?

BackgroundChronic lung diseases (CLDs), responsible for 4 million deaths globally every year, are increasingly important in low- and middle-income countries where most of the global mortality due to CLDs currently occurs. As existing health systems in resource-poor contexts, especially sub-Saharan Africa (SSA), are not generally oriented to provide quality care for chronic diseases, a first step in re-imagining them is to critically consider readiness for service delivery across all aspects of the existing system.MethodsWe conducted a mixed-methods assessment of CLD service readiness in 18 purposively selected health facilities in two differing SSA health system contexts, Tanzania and Sudan. We used the World Health Organization’s (WHO) Service Availability and Readiness Assessment checklist, qualitative interviews of key health system stakeholders, health facility registers review and assessed clinicians’ capacity to manage CLD using patient vignettes. CLD service readiness was scored as a composite of availability of service-specific tracer items from the WHO service availability checklist in three domains: staff training and guidelines, diagnostics and equipment, and basic medicines. Qualitative data were analysed using the same domains.ResultsOne health facility in Tanzania and five in Sudan, attained a CLD readiness score of ≥ 50 % for CLD care. Scores ranged from 14.9 % in a dispensary to 53.3 % in a health center in Tanzania, and from 36.4 to 86.4 % in Sudan. The least available tracer items across both countries were trained human resources and guidelines, and peak flow meters. Only two facilities had COPD guidelines. Patient vignette analysis revealed significant gaps in clinicians’ capacity to manage CLD. Key informants identified low prioritization as key barrier to CLD care.ConclusionsGaps in service availability and readiness for CLD care in Tanzania and Sudan threaten attainment of universal health coverage in these settings. Detailed assessments by health systems researchers in discussion with stakeholders at all levels of the health system can identify critical blockages to reimagining CLD service provision with people-centered, integrated approaches at its heart.

Building structural competency through community engagement.

The importance of addressing the social determinants of health (SDOH) in medical education has been ubiquitously recognised. However, current pedagogical approaches are often limited by inadequate or ahistorical exploration of the fundamental causes of health inequity. Community-engaged pedagogy and structural competency frameworks advocate for progressing from passive SDOH education to directly discussing systemic aetiologies of health inequity through reciprocal partnership with marginalised communities. Herein, we describe the development and exploratory evaluation of a community-engaged structural competency curriculum implemented in 2019 at the University of Nebraska Medical Center. Our curriculum explored the downstream impacts of sociopolitical structures on local health inequities. We engaged university, health system and community stakeholders throughout curriculum development, implementation and evaluation. Curricular components included didactic lectures, reflective writing assignments and a community-based, stakeholder-led experience in North Omaha. We used inductive thematic analysis to explore free-text responses to a post-curriculum survey. Eighteen community stakeholders, eleven multidisciplinary UNMC facilitators, and all 132 first-year medical students were involved in the curriculum pilot, with 93% and 55.1% of students and faculty/community facilitators, respectively, responding to the post-session evaluation. Analysis revealed themes including widespread desire for community-engaged teaching, appreciation for the hyperlocal focus of curricular content and recognition of the importance of creating space for lived experiences of community members. Co-created by a university-community coalition, our pilot findings highlight the crucial role of community-engaged pedagogy in promoting critical understanding of historic structural inequities and present-day health disparities. Our communities can and should be reciprocal partners in training the physicians of tomorrow.

Snakebite incidents, prevention and care during COVID-19: Global key-informant experiences.

Snakebite envenoming is a long-neglected disease causing significant morbidity and mortality in snakebite endemic low- and middle-income countries (LMICs). Global awareness on snakebite was increasing steadily up to 2020, and an increasing number of countries began to acknowledge the issue, when coronavirus disease 2019 (COVID-19) started to have an unprecedented impact on societies and health systems. To better understand how snakebite incidents, prevention and care are being affected during this global emergency, we collected perspectives of snakebite community- and health system stakeholders in a qualitative key-informant study. An open-ended survey and semi-structured interviews were conducted to gather information on changes in snakebite occurrence and circumstances, community responses, access to care and health outcomes in LMICs since the COVID-19 pandemic. Forty-three informants from 21 countries participated in the study. Based on informants' experiences, in spite of COVID-19 lockdowns, exposure to snakes did not change in many rural agrarian communities, where incidences are usually highest. However, we did find several access to care issues relating to avoidance of formal care, transport barriers, overburdened healthcare systems and -providers, and antivenom manufacturing and supply disruptions, which were unique per context. On a brighter note, ventilator availability had increased in several countries, although not automatically benefitting snakebite patients directly. In conclusion, we found apparent effects of the COVID-19 pandemic on snakebite prevention and care, although its severity was highly context- and time-dependent. Interactions between the pandemic effects and snakebite incidents most severely impact remote rural communities, showing the need to invest in community-based prevention and care.

Incentivising doctor attendance in rural Bangladesh: a latent class analysis of a discrete choice experiment

ObjectiveDoctor absenteeism is widespread in Bangladesh, and the perspectives of the actors involved are insufficiently understood. This paper sought to elicit preferences of doctors over aspects of jobs in rural...

826-P: Application of Health Services Outcome Research Approaches to Refine Pragmatic Trial Design during COVID-19

Design of a pragmatic trial requires planning of key components (cohort identification, participant recruitment, consent and enrollment, intervention delivery, and outcomes measurements). The delivery of healthcare was significantly disrupted by COVID-19; this also affected research. We applied health services and outcomes research (HSOR) methods to inform design adaptations of trial components. The trial is an intervention to improve self-care of patients with diabetes mellitus (DM), discharged from the hospital on insulin. Key informant interviews, clinical observations (N=5), patient tracers (N=5), and operational data were gathered from health system stakeholders (N=9), clinicians (N=20), and measurement experts (N=2). Table 1 describes the trial components, HSOR approaches, data sources, and results. A cohort identification algorithm was created using enterprise data warehouse (EDW) data and validated by chart review, and 3 clinical care process maps were produced. Multiple options for each trial component, allowing for flexibility should care disruptions occur, were identified and pretested (N=5). HSOR approaches are effective to rapidly adapt trial design components, even during healthcare delivery disruptions that threaten research. Application of these approaches should be considered as a strategy to design resilient, flexible, and effective pragmatic trials.View largeDownload slideView largeDownload slide DisclosureP. Wax: None. C. Barnard: None. R. T. Ackermann: None. J. L. Holl: None. A. Wallia: Research Support; Self; Eli Lilly and Company, Novo Nordisk, UnitedHealth Group. R. Khorzad: None. C. M. Yu: None. E. K. Touma: None. A. Rosales: None. G. Prince: None. K. Coyne: None. S. Bailey: Consultant; Self; Luto UK, Pfizer Inc., Sanofi US, University of Westminster (UK), Research Support; Self; Eli Lilly and Company, Gordon and Betty Moore Foundation, Lundbeck, Merck & Co., Inc., National Institutes of Health, Pfizer Inc. T. Pollack: None.FundingAgency for Healthcare Research and Quality (3R18HS026143-02S1)

Stakeholder Perspectives of Attributes and Features of Context Relevant to Knowledge Translation in Health Settings: A Multi-Country Analysis.

Context is recognized as important to successful knowledge translation (KT) in health settings. What is meant by context, however, is poorly understood. The purpose of the current study was to elicit tacit knowledge about what is perceived to constitute context by conducting interviews with a variety of health system stakeholders internationally so as to compile a comprehensive list of contextual attributes and their features relevant to KT in healthcare. A descriptive qualitative study design was used. Semi-structured interviews were conducted with health system stakeholders (change agents/KT specialists and KT researchers) in four countries: Australia, Canada, the United Kingdom, and the United States. Interview transcripts were analyzed using inductive thematic content analysis in four steps: (1) selection of utterances describing context, (2) coding of features of context, (3) categorizing of features into attributes of context, (4) comparison of attributes and features by: country, KT experience, and role. A total of 39 interviews were conducted. We identified 66 unique features of context, categorized into 16 attributes. One attribute, Facility Characteristics, was not represented in previously published KT frameworks. We found instances of all 16 attributes in the interviews irrespective of country, level of experience with KT, and primary role (change agent/KT specialist vs. KT researcher), revealing robustness and transferability of the attributes identified. We also identified 30 new context features (across 13 of the 16 attributes). The findings from this study represent an important advancement in the KT field; we provide much needed conceptual clarity in context, which is essential to the development of common assessment tools to measure context to determine which context attributes and features are more or less important in different contexts for improving KT success.

How Digital Storytelling Applied in Health Profession Education: A Systematized Review.

Introduction: Storytelling is one of the earliest ways to share scientific advancements and discoveries. The advent of technology has updated this ancient art into a digitalized form. The boundaries between the digital storytelling (DST), and other types of videos are unclear. Therefore, in this review, the process, aim, producers, and uses of DST in health profession education have been reviewed.Methods:This study is a systematized review, which is in nature like a systematic review with only a few differences in the comprehensive search and quality assessment procedure. All studies, whose duplicates were removed, were retrieved from Science Direct, PubMed, and Scopus databases or through google scholar search engine screened in 3 stages: title, abstract and full study. All journal articles including experimental, case study and case report, mixed method, and qualitative studies in English language in the field of health profession education were chosen for this review after being evaluated based on QUESTS dimensions.Results: In total, 35 articles were included in the review. The studies had been done in health promotion, nursing education, medical education, patient education, social work education, and community health education. In some of these studies, the producers and users of digital stories were different, which is in contrast with center for digital storytelling that emphasizes the process of DST. The results of this review showed that all stakeholders of health system could be producers of digital stories with various aims; e.g. community health, empathy promotion, attitude and behavior change, clinical thinking, and skills improvement.Conclusion: This systematized review indicated that DST has some applications in different subjects in different fields of health professions and with a potential to be used by different stakeholders of health system. According to the definition of DST, digital storytelling involves the process of writing a script to produce a digital story by one individual or a group. Consequently, there is a difference between DST and producing a digital story. Therefore, researchers should consider the correct use of this term in their studies. Although few interventional and high-quality studies have been conducted in this area, further quantitative and qualitative research is suggested.

Facilitators and Barriers to Implementation of Long-Acting Reversible Contraceptive Services for Adolescent Girls and Young Women in Gaborone, Botswana.

Botswana has a high pregnancy rate among adolescent girls and young women (AGYW). Long-acting reversible contraceptive (LARC) use among AGYW in Botswana is low, despite its high effectiveness for preventing pregnancy. Using an implementation science framework, we assessed barriers and facilitators to LARC implementation among AGYW in Botswana. Cross-sectional mixed methods. Gaborone, Botswana. Twenty sexually active AGYW ages 18-24 years; 20 health system stakeholders. Surveys and semistructured interviews grounded in the Consolidated Framework for Implementation Research. Themes reflecting barriers and facilitators of LARC implementation. The median age for AGYW was 22 (interquartile range, 21-23) years. Twenty percent were using an implant and none had ever used an intrauterine device. Barriers and facilitators of LARC implementation spanned factors at each Consolidated Framework for Implementation Research domain: (1) LARC characteristics like side effects; (2) the clinics' inner settings, including availability of youth-friendly services; (3) characteristics of health system stakeholders, such as LARC skills, and AGYW experiences, attitudes, and beliefs about LARCs; (4) the outer setting external to clinics and Botswana's health system including reproductive health law and policy for minor adolescents; and (5) the implementation process level such as the availability of free or low-cost LARCs. We identified multilevel, context-specific factors that affect LARC implementation. Our findings can inform the development of interventions to increase LARC implementation in Botswana by addressing intersecting factors across patient, clinic, health system, and sociopolitical levels, such as providing confidential services to minors and improving LARC training and supply chain pipelines.

98179 Identifying Low-Value Care Across A Statewide Health System: Collaboration Between Quality, Population Health, Informatics, and Health Services Research

ABSTRACT IMPACT: This project demonstrates that addressing low-value care, which has the potential to cause patient harm, relies on novel data tools and collaboration between health system and research stakeholders. OBJECTIVES/GOALS: Reducing low-value care, or patient care that offers no net benefit in specific clinical scenarios, is an important approach to improving value as it can simultaneously lower health care spending and improve quality. We describe an initiative to identify such care in a large statewide employer. METHODS/STUDY POPULATION: Claims data for self-funded University of California (UC) Preferred Provider Organization (PPO) plan members during 2019 were abstracted from the University of California Health (UCH) Clinical Data Warehouse, a unique central database that includes electronic medical record data from >5 million patients across UC medical campuses and all claims from UC self-funded health plans. UCH spans six academic health systems across California. The Milliman MedInsight Health Waste Calculator, a proprietary algorithm-based software tool, was used to identify low-value care and estimate associated spending. The HWC measures 48 low-value services using recommendations from the Choosing Wisely Campaign, the US Preventive Services Task Force, and other clinical specialty guidelines. RESULTS/ANTICIPATED RESULTS: Of 43,882 members of the UC PPO, 11,174 (25.4%) received at least one low-value service. The HWC identified 50,103 eligible services and classified 35% as low-value. Total spending on low-value services ranged between $2,209,516 and $5,089,866, based on a more or less conservative estimate. Across the five sites, the proportion of low-value services ranged from 31% to 39%. Five services comprised 65% of costs from low-value care: annual EKGs, preoperative baseline labs for low-risk surgeries, vitamin D deficiency screening, imaging for eye disease, and headache imaging. The top five services by order frequency were annual EKGs, vitamin D tests, preoperative labs, antibiotics for upper respiratory infections, and imaging for eye disease. DISCUSSION/SIGNIFICANCE OF FINDINGS: Low-value care is prevalent and costly within a large statewide employer. Collaborative multidisciplinary partnerships between employers, health systems, informatics, and researchers can leverage existing data to identify opportunities for improving the value of care for covered populations.

Consensus study on the health system and patient-related barriers for lung cancer management in South Africa.

BackgroundLung cancer is the highest incident cancer globally and is associated with significant morbidity and mortality particularly if identified at a late stage. Poor patient outcomes in low- and middle-income countries (LMIC’s) might reflect contextual patient and health system constraints at multiple levels, that act as barriers to prevention, disease recognition, diagnosis, and treatment. Lung cancer screening, even for high-risk patients, is not available in the public health sector in South Africa (SA), where the current HIV and tuberculosis (TB) epidemics often take precedence. Yet, there has been no formal assessment of the individual and health-system related barriers that may delay patients with lung cancer from seeking and accessing help within the public health care system and receiving the appropriate and effective diagnosis and treatment. This study aimed to derive consensus from health-system stakeholders in the urban Gauteng Province of SA on the most important challenges faced by the health services and patients in achieving optimum lung cancer management and to identify potential solutions.MethodsThe study was undertaken among 27 participant stakeholders representing clinical managers, clinicians, opinion leaders from the public health sector and non-governmental organisation (NGO) representatives. The study compromised two components: consensus and engagement. For the consensus component, the Delphi Technique was employed with open-ended questions and item ranking from five rounds of consensus-seeking, to achieve collective agreement on the most important challenges faced by patients and the health services in achieving optimal lung cancer management. For the engagement component, the Nominal Group Technique was used to articulate ideas and reach an agreement on the group’s recommendations for solution strategies and approaches.ResultsPublic health sector stakeholders suggested that a lack of knowledge and awareness of lung cancer, and the apparent stigma associated with the disease and its risk factors, as well as symptoms and signs, are critical to treatment delay. Furthermore, delays in up-referral of patients with suspected lung cancer from district health care level were attributed to inadequate knowledge arising from a lack of in-service training of nurses and doctors regarding oncologic symptoms, risk factors, need for further investigation, interpretation of x-rays and available treatments. At a tertiary level, participants suggested that insufficient availability of specialised diagnostic resources (imaging, cytological and pathological services including biomolecular assessment of lung cancer), theatres, cardiothoracic surgeons, and appropriate therapeutic modalities (chemotherapeutic agents and radiation oncology) are the main barriers to the provision of optimal care. It was suggested that a primary prevention programme initiated by the government that involves private-public partnerships may improve lung cancer management nationally.ConclusionsConsiderable barriers to the early identification and treatment of lung cancer exist. Finding solutions to overcome both individual and health-system level obstacles to lung cancer screening and management are vital to facilitate early identification and treatment, and to improve survival. Furthermore, research on inexpensive biomarkers for asymptomatic disease detection, the introduction of diagnostic imaging tools that utilise artificial intelligence to compensate for inadequate human resources and improving clinical integration across all levels of the healthcare system are essential.

Medication use and its impact on high-cost health care users among older adults: protocol for the population-based matched cohort HiCOSTT study.

Background:Health interventions and policies for high-cost health care users (HCUs) who are older adults need to be informed by a better understanding of their multimorbidity and medication use. This study aims to determine the financial contribution of medications to HCU expenditures and explore whether potentially inappropriate prescribing is associated with incident HCU development.Methods:This is a protocol for a retrospective population-based matched cohort analysis of incident older adult HCUs (those with the highest 5% of costs and 66 years of age or older) in Ontario during fiscal year 2013. We will obtain person-level data for the index year and year before HCU status from health administrative databases and match each HCU to 3 non-HCUs based on age, sex and geographic location. Average annual medication costs (per patient) and the ratio of medication to total health care costs (at population level) will be examined over the HCU transition period and compared with non-HCUs. We will explore potential quality improvement areas for prescribing by analyzing chronic conditions and the use of medications with a strong evidence base for either clinical benefit or risk of harms outweighing benefits in older adults with these diagnoses. The relation between these medication classes and incident HCU status will be explored using logistic regression.Interpretation:Using a matched cohort design and focusing on incident rather than prevalent HCUs, this protocol will explore our hypotheses that medications and the quality of their prescribing may be important triggers of HCU status and facilitate the identification of potential preventive clinical interventions or policies. Dissemination of results will occur via publications in peer-reviewed journals, presentations at conferences and academic settings, and knowledge translation activities with relevant health system and patient stakeholder groups. Study registration:Clinicaltrials.gov, no. NCT02815930

Epidemiology of End-Stage Kidney Disease on Renal Replacement Therapy: 35 Years Analysis Study Nephrologists.

Incidence and prevalence of end-stage kidney disease (ESKD) population on renal replacement therapy (RRT) for some of the nations are well published. Oman's publication on this aspect is limited and therefore, this study was conducted. This study analyzed the data obtained from the RRT register in Oman. The main measurements and aim are to identify the incidence and prevalence of Oman's treated RRT population (1983-2018) with a major focus on the hemodialysis (HD) cohort. The year 1983 is the year when renal care was started in Oman. The total number of patients registered on Oman's RRT register of the central renal dialysis center from 1983 to 2010 was 3524, distributed among the following treatment cohorts; HD, 2328 patients (66%); kidney transplant, 1,144 patients (32.5%); peritoneal dialysis, 52 patients (1.5%). However, the treated patients alive on HD by end of 2018 were 2023. The dialysis sub-population increased from 35 patients in 1983 to 2023 patients in 2018. The recorded incidence registered in 1983 was 34 patients, in 1986 was 33, in 2013 was 168, in 2015 was 230, and in 2018 was 350 RRT treated patients per million population of Oman. There is a progressive rise of the incidence and prevalence of Oman's RRT population. This rise is similar to many nations, especially developing countries that are being faced with the rising trend of noncommunicable diseases (NCD). The health system and other stakeholders ought to take various stringent policies to ameliorate the progressive increase of NCD and hence, reduce the burden of chronic kidney disease and ESKD.

Evidence of past and current collaborations between traditional health practitioners and biomedical health practitioners: a scoping review protocol

IntroductionHealthcare seekers around the globe use more than one healthcare system, with most using the traditional and the Western approaches concurrently. To date, little collaboration between the two systems has...

Artificial intelligence-based imaging analytics and lung cancer diagnostics: Considerations for health system leaders.

Lung cancer is a leading cause of cancer death in Canada, and accurate, early diagnosis are critical to improving clinical outcomes. Artificial Intelligence (AI)-based imaging analytics are a promising healthcare innovation that aim to improve the accuracy and efficiency of lung cancer diagnosis. Maximizing their clinical potential while mitigating their risks and limitations will require focused leadership informed by interdisciplinary expertise and system-wide insight. We convened a knowledge exchange workshop with diverse Saskatchewan health system leaders and stakeholders to explore issues surrounding the use of AI in diagnostic imaging for lung cancer, including implementation opportunities, challenges, and priorities. This technology is anticipated to improve patient outcomes, reduce unnecessary healthcare spending, and increase knowledge. However, health system leaders must also address the needs for robust data, financial investment, effective communication and collaboration between healthcare sectors, privacy and data protections, and continued interdisciplinary research to achieve this technology's potential benefits.

Developing strategies to attract, retain and support midwives in rural fragile settings: participatory workshops with health system stakeholders in Ituri Province, Democratic Republic of Congo

BackgroundMidwifery plays a vital role in the quality of care as well as rapid and sustained reductions in maternal and newborn mortality. Like most other sub-Saharan African countries, the Democratic Republic of Congo experiences shortages and inequitable distribution of health workers, particularly in rural areas and fragile settings. The aim of this study was to identify strategies that can help to attract, support and retain midwives in the fragile and rural Ituri province.MethodsA qualitative participatory research design, through a workshop methodology, was used in this study. Participatory workshops were held in Bunia, Aru and Adja health districts in Ituri Province with provincial, district and facility managers, midwives and nurses, and non-governmental organisation, church medical coordination and nursing school representatives. In these workshops, data on the availability and distribution of midwives as well as their experiences in providing midwifery services were presented and discussed, followed by the development of strategies to attract, retain and support midwives. The workshops were digitally recorded, transcribed and thematically analysed using NVivo 12.ResultsThe study revealed that participants acknowledged that most of the policies in relation to rural attraction and retention of health workers were not implemented, whilst a few have been partially put in place. Key strategies embedded in the realities of the rural fragile Ituri province were proposed, including organising midwifery training in nursing schools located in rural areas; recruiting students from rural areas; encouraging communities to use health services and thus generate more income; lobbying non-governmental organisations and churches to support the improvement of midwives’ living and working conditions; and integrating traditional birth attendants in health facilities. Contextual solutions were proposed to overcome challenges.ConclusionMidwives are key skilled birth attendants managing maternal and newborn healthcare in rural areas. Ensuring their availability through effective attraction and retention strategies is essential in fragile and rural settings. This participatory approach through a workshop methodology that engages different stakeholders and builds on available data, can promote learning health systems and develop pragmatic strategies for the attraction and retention of health workers in fragile remote and rural settings.

Integration of perinatal mental health care into district health services in Uganda: Why is it not happening? The Four Domain Integrated Health (4DIH) explanatory framework

The Sustainable Development Goals recognise mental health and well-being as a target area, however, mobilizing funding and prioritisation of the same remains a challenge. Perinatal mental health care has the potential for incorporation and integration across the overall maternal health agenda, and can be especially relevant for low- and middle-income countries in their overall health systems strengthening strategies. This study aimed at qualitatively situating the extent to which integration of perinatal mental health care into maternal health care was considered desirable, possible and opportune within the existing policy and service-delivery environment in Uganda. A total of 81 in-depth interviews and nine focus group discussions (N = 64) were conducted with a variety of national, district, health system and community-level stakeholders. Data were analysed thematically using theory- and data-driven codebooks in NVivo 11. Analysis of the desirability, possibility and opportunity for integrating perinatal mental health care within the Ugandan district health system, highlights that concerned stakeholders perceive this as a worthwhile endeavour that would benefit the communities as well as the health system as a whole. Based on these current realities and ideal scenarios, a tentative explanatory framework that brings together various perspectives – that is, the perceived nature of the health problem, local and national health system issues, alternative systems of care and support, and international global perspectives – was constructed. The framework needs further validation but already hints at the need for global, national and local forces to concurrently rally behind the inclusion and integration of perinatal mental health care, especially at the primary care level in low- and middle-income contexts. If the global health community is poised to achieve high quality, women-centered care and people-centered health systems across the lifespan, then the sustainable integration of mental health care into general health care, is a commitment that can no longer be delayed.