Ward Level Research Articles

Users� Perspectives on Community Engagement in Local Health Governance Structures in Itilima and Bariadi District Councils in Simiyu Region, Tanzania

The aim of this study is to investigate Users’ perspectives on community engagement in the health governance structures at the sub-district levels in two rural districts in Tanzania. The specific objectives of the study are: i) to examine health service Users’ awareness about the existence of local health governance structures, ii) to examine the level of community engagement and functionality of the structures, and iii) to identify the contextual factors affecting the functionality of local health governance structures. The study draws on empirical data collected from 281 service users, health service boards and committees’ members and key informants through questionnaire survey, focus group discussions and semi-structured interviews. The study found limited health service Users’ awareness about the existence of health governance structures partly because some health facilities lacked the boards and committees and in some cases community members were not involved in the selection of community representatives through their village assemblies. Further, most of the community health governance structures were not functional as had infrequent meetings and varied composition contrary to the guidelines for their establishment. Consequently, community engagement in these structures was very limited. The factors affecting functionality of these structures included lack of clarity among stakeholders on the procedures for establishing the structures, limited capacity of community members on their roles and responsibilities in the structures and delays in establishing and replacing expired service boards and committees. It is concluded that, the purpose of improving healthcare service delivery through improved community participation and governance in the local health governance structures is still far from being realised. Thus, the district councils should strengthen the functionality of the health governance structures by creating awareness among stakeholders at the ward, village and health facility levels about the guidelines for establishing and functioning of the health governance structures.

The implementation process of the Workload Indicators Staffing Need (WISN) method by WHO in determining midwifery staff requirements in Greek Hospitals.

INTRODUCTIONOne of the greatest challenges in the healthcare field is planning the health workforce under limited financial resources while being fully capable of responding to an affordable, fair and efficient healthcare system. This study aimed to demonstrate the implementation process of the health workforce planning tool ‘Workload Indicators of Staffing Needs’ introduced by the World Health Organization.METHODSA descriptive and cross-sectional study was carried out at four (two public and two private) hospitals in Greece, to estimate midwifery staff requirements at ward level during 2015–2016, using the WISN software tool. Focus group discussions, structured interviews and annual service statistics from the hospitals’ records were used to obtain data.RESULTSResults for both private hospitals showed a shortage in the number of midwives. However, after combining the interpretation of the results, as indicated by the WISN methodology and the structured interviews, current and required staffing is in balance in both. On the other hand, both public hospitals indicate a surplus of midwives (1.83 and 1.33 ratios for the General hospitals in Korinthos and Kalamata, respectively).CONCLUSIONSThis study demonstrated the implementation process of the WISN methodology through its application in midwifery staff at four hospitals in Greece and confirmed its usefulness in estimating staffing requirements. The application of the WISN methodology should be viewed as a vital tool in assessing overstaffing and understaffing through the estimation of workload pressure among different categories of health staff, thus providing the basis for effective health workforce redistribution in Greece.

A framework to facilitate the promotion of women nurses of colour to leadership positions in hospitals

Despite the implementation of the Employment Equity Act in 1998, African and Coloured women are under-represented in leadership positions in private healthcare in South Africa. African nurses are well presented in leadership positions in public healthcare in most provinces except the Western Cape where Coloured nurses have improved leadership representation. This study aimed to develop a framework to facilitate the appointment of women nurses of colour (African and Coloured nurses for the purpose of this study) to leadership positions in hospitals. A concurrent mixed method design was employed comprising a survey and interpretive phenomenology. The study was conducted in public and private hospitals in the Western Cape and Gauteng provinces. Six hundred and eighty-eight professional nurses consented to participate and n = 573 (83%) completed the survey. Five interviews were conducted with nurse leaders in SA and another 40 with persons who had participated in the selection processes of nurses to leadership positions. The quantitative findings revealed caution to admit that the Employment Equity Act contributed to the promotion of African, Coloured and Indian nurses, a divide between nursing management and nurses on ward level, inferior viewing of African and the superior viewing of White nurses. Qualitative findings suggested efforts to consider the Employment Equity Act, racial discrimination, and questionable promotion practices. Meta-inferences were drawn from the qualitative and quantitative findings. A framework was developed from these meta-inferences that focused on credible promotion practices, diversity training, succession-planning and healthy managerial structures.

Relationship between healthy elderly individual social capital and health according to ward level in Tomi City, Nagano Prefecture: an ecological study.

Objectives: The aims of this study were 1) to elucidate the relationship between social capital and health by ward in Tomi City, Nagano Prefecture, in order to clarify the regional social resources available to support long-term care prevention utilizing self- and mutual support of regional residents and 2) to comprehensively investigate the activation of regional networks.Materials and Methods: We analyzed elderly (aged 65 years or older) individual survey data from 7,199 residents from all wards within Tomi City in 2014 (number of valid responses: 5,546; valid response rate: 77.0%). The social capital indicators used for the analysis included participation in community activities, regional managerial position experience, and general trust. The health indicators included self-rated mental health, activities of daily living, and depression. Standards for a “good” result for each indicator were established, and the percentages of each were tallied up by ward. Spearman’s rank correlation coefficient and principal component analysis were used to investigate correlations between social capital and health.Results: The results for overall respondents indicated correlations between participation in sports and hobbies and activities of daily living (p<0.01) and self-rated mental health (p<0.05). Participation in nonprofit organizations/volunteer activities and participation in community center workshops exhibited correlations with activities of daily living (both p<0.05). In respondents aged 65–74 years, participation in community center workshops and general trust were found to be correlated with activities of daily living (both p<0.05). Meanwhile, in respondents aged 75 years or older, correlations were noted between participation in sports and hobbies and participation in nonprofit organizations/volunteer activities and activities of daily living (p<0.05 and p<0.01, respectively). By creating a distribution map using principal component analysis, we were able to grasp the characteristics of the distribution of “community participation/connections with people” and “health” in each ward.Conclusions: Our results point the way forward for future long-term care prevention support in Tomi City by clarifying the correlation between social capital and health by ward.

Demand management of weekend haematology and clinical biochemistry requests.

Increasing demand for laboratory testing at weekends is common but little is known about its appropriateness. An audit was conducted in a large district hospital of routine haematology and clinical biochemistry requests ordered over two weekends. Appropriateness was assessed by review of ordered tests compared with clinical records by a qualified chemical pathologist. Profiles requested on phlebotomy included full blood count (76%), renal profile (91%), C-reactive protein (41%), liver function tests (18%) and another test in 18%. Phlebotomy was likely unnecessary in 47.5% of episodes while 60.8% of requested assays were graded probably unnecessary or unnecessary. At ward level the number of requests averaged 37 (median 32; range 2-76) totalling 446 separate profiles or assays. There was no difference in phlebotomy requests by ward (P=0.19). Differences were observed in ordered tests (P=0.005) which were caused by one outlier ward with a low request rate. A large number of unnecessary common tests seem to be carried out at weekends as part of the routine care. Implementation of demand management through education and if necessary electronic limitation of requests may be useful to control laboratory workloads.

“Change is what can actually make the tough times better”: A patient‐centred patient safety intervention delivered in collaboration with hospital volunteers

BackgroundThe PRASE (Patient Reporting and Action for a Safe Environment) intervention provides a way to systematically collect patient feedback to support service improvement. To provide a sustainable mechanism for the PRASE intervention, a 2‐year improvement project explored the potential for hospital volunteers to facilitate the collection of PRASE feedback.ObjectiveTo explore the implementation of the PRASE intervention delivered in collaboration with hospital volunteers from the perspectives of key stakeholders.DesignA qualitative case study design was utilized across three acute NHS trusts in the United Kingdom between March 2016 and October 2016. Ward level data (staff interviews; action planning meeting recordings; implementation fidelity information) were analysed taking a pen portrait approach. We also carried out focus groups with hospital volunteers and interviews with voluntary services/patient experience staff, which were analysed thematically.ResultsWhilst most ward staff reported feeling engaged with the intervention, there were discordant views on its use and usefulness. The hospital volunteers were positive about their involvement, and on some wards, worked with staff to produce actions to improve services. The voluntary services/patient experience staff participants emphasised the need for PRASE to sit within an organisations’ wider governance structure.ConclusionFrom the perspective of key stakeholders, hospital volunteers facilitating the collection of PRASE feedback is a feasible means of implementing the PRASE intervention. However, the variability around ward staff being able to use the feedback to make changes to services demonstrates that it is this latter part of the PRASE intervention cycle that is more problematic.

Effectiveness and cost effectiveness of pharmacist input at the ward level: a systematic review and meta-analysis

Pharmacists play important role in ensuring timely care delivery at the ward level. The optimal level of pharmacist input, however, is not clearly defined. To systematically review the evidence that assessed the outcomes of ward pharmacist input for people admitted with acute or emergent illness. The protocol and search strategies were developed with input from clinicians. Medline, EMBASE, Centre for Reviews and Dissemination, The Cochrane Library, NHS Economic Evaluations, Health Technology Assessment and Health Economic Evaluations databases were searched. Inclusion criteria specified the population as adults and young people (age >16 years) who are admitted to hospital with suspected or confirmed acute or emergent illness. Only randomised controlled trials (RCTs) published in English were eligible for inclusion in the effectiveness review. Economic studies were limited to full economic evaluations and comparative cost analysis. Included studies were quality-assessed. Data were extracted, summarised. and meta-analysed, where appropriate. Eighteen RCTs and 7 economic studies were included. The RCTs were from USA (n = 3), Sweden (n = 2), Belgium (n = 2), China (n = 2), Australia (n = 2), Denmark (n = 2), Northern Ireland, Norway, Canada, UK and Netherlands. The economic studies were from UK (n = 2), Sweden (n = 2), Belgium and Netherlands. The results showed that regular pharmacist input was most cost effective. It reduced length-of-stay (mean = -1.74 days [95% CI: 2.76, -0.72], and increased patient and/or carer satisfaction (Relative Risk (RR) = 1.49 [1.09, 2.03] at discharge). At £20,000 per quality-adjusted life-year (QALY)-gained cost-effectiveness threshold, it was either cost-saving or cost-effective (Incremental Cost Effectiveness Ratio (ICER) = £632/QALY-gained). No evidence was found for 7-day pharmacist presence. Pharmacist inclusion in the ward multidisciplinary team improves patient safety and satisfaction and is cost-effective when regularly provided throughout the ward stay. Research is needed to determine whether the provision of 7-day service is cost-effective.

Compliance with the "Baby-friendly Hospital Initiative for Neonatal Wards" in 36 countries.

In 2012, the Baby‐friendly Hospital Initiative for Neonatal Wards (Neo‐BFHI) began providing recommendations to improve breastfeeding support for preterm and ill infants. This cross‐sectional survey aimed to measure compliance on a global level with the Neo‐BFHI's expanded Ten Steps to successful breastfeeding and three Guiding Principles in neonatal wards. In 2017, the Neo‐BFHI Self‐Assessment questionnaire was used in 15 languages to collect data from neonatal wards of all levels of care. Answers were summarized into compliance scores ranging from 0 to 100 at the ward, country, and international levels. A total of 917 neonatal wards from 36 low‐, middle‐, and high‐income countries from all continents participated. The median international overall score was 77, and median country overall scores ranged from 52 to 91. Guiding Principle 1 (respect for mothers), Step 5 (breastfeeding initiation and support), and Step 6 (human milk use) had the highest scores, 100, 88, and 88, respectively. Step 3 (antenatal information) and Step 7 (rooming‐in) had the lowest scores, 63 and 67, respectively. High‐income countries had significantly higher scores for Guiding Principles 2 (family‐centered care), Step 4 (skin‐to‐skin contact), and Step 5. Neonatal wards in hospitals ever‐designated Baby‐friendly had significantly higher scores than those never designated. Sixty percent of managers stated they would like to obtain Neo‐BFHI designation. Currently, Neo‐BFHI recommendations are partly implemented in many countries. The high number of participating wards indicates international readiness to expand Baby‐friendly standards to neonatal settings. Hospitals and governments should increase their efforts to better support breastfeeding in neonatal wards.

Multidisciplinary views towards the clinical pharmacist: a hospital palliative cancer care team perspective in Malta

To explore the views of the multidisciplinary healthcare team towards the role of the clinical pharmacist within the palliative care unit of an oncology hospital in Malta. At present, in Malta, clinical pharmacists are not routinely involved in care provision with palliative cancer care teams and there is a need to consider their role. Three 60 min audio-recorded heterogeneous focus groups were conducted with eligible healthcare providers at Sir Anthony Mamo Oncology Centre in Mater Dei Hospital. The topic guide was based on literature and was assessed for face and content validity by an expert panel. The transcripts were analysed using the framework method whereby emerging categories and themes were devised. A total of four doctors, ten ward nurses, two Hospice community nurses, three nursing aides, one psychologist and six allied healthcare professionals consented to participate. The framework analysis resulted in four main categories namely: (1) pharmacists as the expert reference point; (2) availability of clinical pharmacists in providing clinical services on ward level; (3) attitudes towards potential clinical services provided by clinical pharmacists; and (4) clinical pharmacists as a link with the community on pharmaceutical matters. The general view of healthcare providers on the clinical pharmacist's role in palliative cancer care was largely supportive and positive. This should encourage policy makers to introduce clinical pharmacy services within this setting.

Short-Term Effects of Air Pollution on Cerebrovascular Diseases

Background/AimPM2.5 is well-known to increase cerebrovascular diseases. However, there is a paucity of studies for the Japanese population, especially for Tokyo residents. In this study, we examined the association between exposure to hourly PM2.5 levels and acute cerebrovascular diseases using records on emergency department (ED) visit in Tokyo, Japan. MethodsWe used data on emergency department visits through ambulance dispatch (n&amp;#61;1,361,302) in the entire Tokyo prefecture from 2015 to 2016. Variables include date and time of incidence, age, sex, occurrence location at the ku-level (approx. ward or city level), and symptom/cause of dispatch recorded by paramedics. We selected non-traumatic cerebrovascular incidents (n&amp;#61;45,748). The PM2.5 data were acquired from the nearest air quality monitoring station to the occurrence location. Then, they were linked with the ED visits based on occurrence date and time. The bi-directional case-crossover study design was applied to investigate the acute cerebrovascular events controlling for ambient temperature, humidity, and day of week. ResultsA 10 &amp;#956;g/m3 increase in PM2.5 level at the same hour was associated with a 1.01% (95% CI: 0.37 to 1.65) increase in ED visit related to cerebrovascular diseases. A stronger association was found in people aged between 50 and 70 (1.55%, 95% CI: 0.34 to 2.77). The same increase in PM2.5 was also associated with an increase in stroke (0.87%, 95%CI: 0.16 to 1.60). ConclusionsExposure to higher levels of PM2.5 was associated with increased ED visits pertinent to acute cerebrovascular diseases.

Self‐management intervention using teach‐back for people with heart failure in Vietnam: A cluster randomized controlled trial protocol

Globally, the increasing prevalence of heart failure is a burden on health-care systems, especially in under-resourced countries, such as Vietnam. We describe a prospective single-site, cluster randomized controlled trial of an intervention designed to teach adult patients about heart failure and how to undertake self-care activities. The intervention, delivered by a nurse, comprises of an individual teaching session using teach-back, a heart failure booklet, weighing scales, a diary to document daily weight, and a follow-up phone call 2 weeks after hospital discharge. Teach-back is a process of asking patients to repeat information and for the nurse to fill any gaps or misunderstanding until adequate understanding is demonstrated. The control group will receive usual education plus the heart failure (HF) booklet. A total of 140 participants will be allocated into two study groups. The level of randomization is at the ward level. The primary outcome (HF knowledge) and secondary outcomes (self-care behaviors and all-cause hospitalizations) will be measured at 1 and 3 months. This study will make an important contribution regarding a protocol of teach-back and chronic disease self-management.

Human Resources Management in the Implementation of School Mapping and Micro Planning of Public Primary Schools in Temeke Municipality, Tanzania

The paper examines human resources management in the implementation of School Mapping (SM) and Micro Planning (MP) of public primary schools in Temeke Municipality, Tanzania. The study was guided by the main question "How was the critical capacity of human resources during the implementation of SM and MP?” The approach used in the study was qualitative employing multiple case studies design. The respondents of the study were 92 while the selected public primary schools were 10. The respondents selected were primary school teachers, head teachers, school committee members and education officers at ward and educational level. Methods of data collection were semi-structured interview, focus group discussion, non-participant observation and documentary review. Data were analyzed using qualitative content analysis. The research findings revealed that there was improvement in the management of human resources as attested in the aspects of recruitment of head teachers, qualifications, training, professional development and motivation in schools. The study concluded that the critical capacity of human resources in public primary school can be enhanced by the implementation of SM and MP. The study recommends that the implementation of SM and MP of public primary school should be an ongoing process as it improves the management of human resources the decentralized level.

English

Decentralization has become an eminent discourse for boosting people&rsquo;s participation in decision making. Arguably, one of the pillars to boost good governance. Nevertheless, various levels of governance, which have resulted from decentralisation by devolution have varied perspectives on rewards for the work they perform especially the lowest namely village and ward levels. The contestation is on who deserves to receive payment for the elected posts. There are diversified opinions on the matter. Some opine that councillors, deserve more pay for their exertion. On the other hand, some opine that village chairpersons deserve pay for their work. Some people opine that both councillors and village chairpersons deserve pay. Hence, the main objective of the study is to find out which cadre deserves more attention to payment between the ward councillor&rsquo;s and village chairpersons. This is a case study design which focused on Hai district in Kilimanjaro. The literature has employed interview as the major information collection strategy. Observation and documentation were used as supportive strategies. The sample was drawn through purposeful sampling from four wards, which is 100% of the sample with which the chairpersons are also the councillors in Hai district. The analysis of information has utilised descriptive analysis, which is cemented on logical reasoning of the contents. The research has concluded that 100% of the respondents were in favour of a village chairperson to be paid than a councillor. In addition, it was evident that village chairperson work is more tasking than councillors.&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; Key words: Decentralization, devolution, councillors, village chairman, development.

Factors in Pulmonary Embolus Diagnosis via CT Pulmonary Angiogram in Patients Undergoing Repair of Proximal Femur Fractures

Background:As imaging technology improves small Pulmonary Emboli (PE) of debatable clinical relevance are increasingly detected leading to higher numbers of patients receiving anticoagulation. Although PE are an important cause of morbidity and mortality in patients undergoing repair of proximal femur fractures, this cohort of patients are at increased falls risk and are therefore largely unsuitable for long term anticoagulant therapy.Objective:1. To review sequential Computed Tomography Pulmonary Angiograms (CTPA) performed in patients who underwent repair of proximal femur fractures at our institution. 2. To establish the perioperative CT imaging performed.Design: A retrospective cross sectional study of all patients undergoing proximal femur fracture repair at a single tertiary referral.Methods:The theatre database was interrogated to reveal all patients undergoing proximal femur fracture repair over a 28 month period from 01/01/12 to 07/04/14 inclusive. This was cross-referenced with the Picture Archiving Communication System (PACS) to establish all imaging undertaken in the perioperative period. CTPA studies performed within the time period of 1 week prior to and 6 months post proximal femur fixation were included. CTPA studies and reports were assessed for quality and findings. D-Dimer results, if performed within 72 hours of the CTPA study, were recorded.Results:1388 patients underwent neck of femur fracture repair in the 28-month study period. Of this cohort 71 CTPA studies were performed in 71 patients (5.2%) with a mean age of 77.8 years (range 38 - 100). 53 (74.6%) of studies were negative for embolus and 17 (23.9%) studies revealed clot in a pulmonary artery (1 saddle embolus, 2 main pulmonary artery emboli, 7 lobar vessel emboli, 2 segmental artery emboli, 5 subsegmental emboli). Overall PE detection rate was 1.2% of our total study population. In all 71 studies, Houndsfield Unit (HU) in the main pulmonary artery (PA) was >200; which is considered to be of satisfactory quality to assess for segmental pulmonary emboli. 32% of patients had D Dimer levels performed, however no relationship with presence of PE on CTPA was demonstrated.Conclusion:The rate of positive CTPA studies in patients undergoing proximal femur fracture repair is 23.9% in our patient population, comparing favorably to published data. This is likely to reflect good compliance with prevention measures at ward level. D-Dimer results are unreliable for PE prediction.

A qualitative study of nurses' perceptions of a behavioural strategies e-learning program to reduce interruptions during medication administration

ObjectivesWe sought to evaluate the perceptions of nurses of an e-learning educational program to encourage the use of behavioural strategies—blocking, engaging, mediating, multitasking, and preventing—to reduce the negative effects of interruptions during medication administration. DesignA qualitative design was used to evaluate the impact of this e-learning educational intervention on nurses' behaviour. SettingsTwo wards (palliative care and aged care) from two different hospitals within a large local health service within Sydney Australia, were included in the study. These wards were also involved in a cluster randomised trial to test the effectiveness of the program. ParticipantsA purposive sample participated comprising nine registered and enrolled nurses certified to conduct medication administration, who had reviewed the educational modules. MethodsTwo focus groups were conducted and these sessions were digitally recorded and transcribed verbatim. Thematic analysis identified seven themes. ResultsThe major themes identified included: perceptions of interruptions, accessing the program, content of the program, impact, maintaining good practice and facilitators and barriers to changing behaviour. ConclusionsThe use of embedded authentic images of patient interruptions and management strategies increased some nurses' perceived use of strategies to manage interruptions. Nurses varied in their perception as to whether they could change their behaviour with some describing change at the individual and ward team levels, while others described patient caseload and other health professionals as a barrier. The use of this innovative educational intervention is recommended for staff orientation, student nurses, medical officers and allied health staff. Further research is required in how this e-learning program can be used in combination with other effective interventions to reduce interruptions.

Speaking up about patient safety concerns: the influence of safety management approaches and climate on nurses' willingness to speak up.

Speaking up is important for patient safety, but healthcare professionals often hesitate to voice their concerns. Direct supervisors have an important role in influencing speaking up. However, good insight into the relationship between managers' behaviour and employees' perceptions about whether speaking up is safe and worthwhile is still lacking. To explore the relationships between control-based and commitment-based safety management, climate for safety, psychological safety and nurses' willingness to speak up. We conducted a cross-sectional survey study, resulting in a sample of 980 nurses and 93 nurse managers working in Dutch clinical hospital wards. To test our hypotheses, hierarchical regression analyses (at ward level) and multilevel regression analyses were conducted. Significantly positive associations were found between nurses' perceptions of control-based safety management and climate for safety (β=0.74; p<0.001), and between the perceived levels of commitment-based management and team psychological safety (β=0.36; p<0.01). Furthermore, team psychological safety is found to be positively related to nurses' speaking up attitudes (B=0.24; t=2.04; p<0.05). The relationship between nurse-rated commitment-based safety management and nurses' willingness to speak up is fully mediated by team psychological safety. Results provide initial support that nurses who perceive higher levels of commitment-based safety management feel safer to take interpersonal risks and are more willing to speak up about patient safety concerns. Furthermore, nurses' perceptions of control-based safety management are found to be positively related to a climate for safety, although no association was found with speaking up. Both control-based and commitment-based management approaches seem to be relevant for managing patient safety, but when it comes to encouraging speaking up, a commitment-based safety management approach seems to be most valuable.

An innovation to improve health outcomes in Amajuba district, KwaZulu-Natal, South Africa

ABSTRACTSystems’ thinking places high value on understanding the context. This study focused on the collection of disaggregated data in order to understand the context, to facilitate improvement of health outcomes. The aim of this article was to assess the implementation of municipal ward-based health data collection (disaggregated data) and health care workers’ perceptions of this data collection process. This cross-sectional study used mixed methods in Amajuba district. The participants were professional nurses at the Primary Health Care level. Of the 131 respondents, 123 (93.9%) collected municipal ward-based health data, and found it useful. Opportunities for improving data collection were identified. Disaggregation of the data at ward level contributes to a better understanding of the target population’s health, assists planning for health needs and enables provision of targeted interventions in order to improve health outcomes, to prevent financial regression and waste of health resources.

Do pay-for-performance incentives lead to a better health outcome?

Pay-for-performance approaches have been widely adopted in order to drive improvements in the quality of healthcare provision. Previous studies evaluating the impact of these programs are limited by either the number of health outcomes or of medical conditions considered. In this paper, we evaluate the effectiveness of a pay-for-performance program on the basis of five health outcomes and across a wide range of medical conditions. The context of the study is Lombardy region in Italy, where a rewarding program was introduced in 2012. The policy evaluation is based on a difference-in-differences approach. The model includes multiple dependent outcomes, which allow quantifying the joint effect of the program, and random effects, which account for the heterogeneity of the data at the ward and hospital level. Our results show that the policy had a positive effect on the hospitals’ performance in terms of those outcomes that can be more influenced by a managerial activity, namely the number of readmissions, transfers and returns to surgery room. No significant changes which can be related to the pay-for-performance introduction are observed for the number of voluntary discharges and for mortality. Moreover, our study shows evidence that the medical wards have reacted more strongly to the pay-for-performance program than the surgical ones, whereas only limited evidence is found in support of a different policy reaction across different types of hospital ownership. Finally, the evaluation found no evidence of a distortion of the hospital behavior aimed at inflating the performance evaluation, such as cream skimming behavior.

Effectiveness of a weekend physiotherapy service on short-term outcomes following hip and knee joint replacement surgery: a quasi-experimental study

Objective: To investigate the effect of an acute weekend physiotherapy service compared to no physiotherapy service on short-term outcomes following lower limb joint replacement. Design: Pre-post intervention (quasi-experimental) study nested within two stepped-wedge cluster randomized controlled trials. Setting: Public tertiary hospital in Melbourne, Australia. Subjects: Consecutive patients undergoing hip and knee replacement. Interventions: This study analysed a subgroup of one cluster of the parent trials where acute weekend physiotherapy services were sequentially discontinued in random order from one cluster at a time. Intervention (at the ward level) included six months of existing acute weekend physiotherapy services (Phase 1; n = 130) followed by six months when these services were discontinued (Phase 2; n = 146). Main measures: Acute hospital length of stay and other short-term patient and hospital measures. Results: Availability of weekend physiotherapy was associated with increased odds of discharge directly home (odds ratio (95% confidence interval): 3.151 (1.039–9.555), P = 0.043) and improved mobility (coefficient: 4.301 (1.500–7.101), P = 0.003). However, hospitalization was perceived as less helpful (coefficient: –1.743 (−2.417 to −1.069), P = 0.013) and acute length of stay was longer, only in multivariable analyses (coefficient: 1.003 (0.105–1.890), P = 0.020) than when weekend physiotherapy services were unavailable. Similar results were observed when examining data according to receipt of weekend physiotherapy services rather than the intervention phase to which each patient was allocated. Conclusion: The weekend physiotherapy service appears to have had beneficial impacts on discharge destination and patient mobility that may outweigh the unfavourable impacts on acute length of stay and patient-perceived helpfulness of hospitalization.

The Application of Para Social Work Training in Physically and Sexually Abused Girls Under 18 Years of Age in Tanzania: A Case Study of Temeke Municipality, Dar es Salaam Region

The article presents a case of Para Social work training which basically aim at explaining how this training is essential in providing care and support to young Girls who are physically and sexually abused in Tanzania. It attempts to explain how the victims’ families with the help of Para Social workers can be linked to much-needed services. The objective of this study was to examine the application of Para Social work training in physically and sexually abused girls in Temeke Municipal, Dar es Salaam region. The study was also set to explore possible measure used to reduce the risk of physically and sexually abuse among young girls in addition to Para Social work training in Temeke Municipal, Dar es Salaam region. A major framework of sociological theory was used. The symbolic interactionism was employed in this study to explore symbolic meanings that community members developed and used in the process of social interaction. The family members of abused girls would interpret the behaviour of the young girls and therefore form the social bond which later was used to inform the community members about the problem that they were facing. This theoretical perspective helped the Para Social worker to make sense of the life experiences of young girls’ and understand their coping strategies including the increasing capacity of Para Social workers to access resources for improving care for young girls and their families. Further the theory increased capacity to understand how Para Social workers could generate the Eight (8) Years Plan for Development which was used in protecting young girls against physical and sexual abuse within their community. The theory enlightens community volunteers and Para Social workers in planning for various interventions in violence against children in Tanzania. Further, the study confirmed that community volunteers and Para Social workers suggested on the use of National Plan of Action for their interventions especially in emerging issues that needed their attention especially in reducing the problem of violence against children in their communities. This perspective helped to capture the behaviour of young girls and how they symbolically navigate their lives. The meaning and significance of young girls and the effect of abuse enable us to capture the social reality of those who dealt with the abuse and the measurement to reduce the problem using their own perspectives. This study used qualitative approach which included in-depth Interview and Focus Group Discussion (FGD). Also purposive sampling was used whereby 50 informants were selected as a sample size of this study. The informants came from Temeke district in Dar es Salaam region.The Findings revealed that, since the development of Para Social work trainings in 2006, most vulnerable children especially young girls have enabled Para Social workers to be fully equipped and be able to apply relevant social policies effectively. Such policies include Sexual Offences Provisional Act of 1988(SOSPA), Child Development Policy of 2008 and the Law of the Child Act number 21 of 2009. Furthermore the Para Social work training has facilitated the process of identifying young girls who is abused. Thereafter Para Social workers have helped the girls’ families to develop and implement a plan of support.The study recommends to Para Social workers that young girls need to be understood in terms of situation and be protected from hazardous condition including physical and sexual abuse within their communities. Further the study recommends that it is important to strengthen child protection systems so that all kinds of abuse are addressed and worked on clearly in their communities. As for policy makers and law makers’ young girls have to be in their agenda for change. Para Social workers participation in this training is important as there are no enough staffs at the ward and village levels who could work for social workers. The availability of Para Social workers will facilitate linkages to available resources which are important for young girls’ growth and development. The attitude and perceptions towards using Para Social workers to help community members including the parents and other family members of young girls need to be changed for the benefit of the community members they serve.