An integrated hospital-district evaluation for communicable diseases in low/middle-income countries

Abstract Background The last two decades saw an extensive effort to design and implement integrated and multidimensional healthcare evaluation systems in high-income countries. However, in low/middle-income countries, few experiences of such systems implementation have been reported in the scientific literature. We developed and piloted an innovative tool to assess the performance of health services provision for communicable diseases in three African countries. Methods A total of 42 indicators, 14 per each communicable disease care pathway (Tuberculosis, Gastroenteritis, and HIV/AIDS), were developed. A sub-set of 23 indicators was included in the evaluation process. The indicators assessed four care phases: prevention, diagnosis, treatment, and outcome. All indicators were calculated for the period 2017-2019, while performance evaluation was performed for 2019. The analysis involved four health districts and their relative hospitals in Ethiopia, Tanzania, and Uganda. Results Substantial variability was observed over time and across the four different districts. In the TB pathway, the majority of indicators scored below the standards and below-average performance was mainly reported for prevention and diagnosis phases. Along the Gastroenteritis pathway, excellent performance was instead evaluated for most indicators and the highest scores were reported in prevention and treatment phases. The HIV/AIDS pathway indicators related to screening and outcome phases were below the average score, while good or excellent performance was registered within the treatment phase. Conclusions The bottom-up approach and stakeholders’ engagement increased local ownership of the process and the likelihood that findings will inform health services performance and quality of care. Despite the intrinsic limitations of data sources, this framework may contribute to promoting good governance, performance evaluation and accountability in settings characterised by multiple healthcare service providers. Key messages • A successful experience in developing and implementing a communicable diseases performance evaluation systems in three sub-Saharan African countries using a bottom-up approach. • The communicable diseases performance evaluation tool helped the data sharing between local healthcare providers and the development of competencies in data collection, analysis and interpretation.


Issue/problem:
The United Kingdom (UK) hosts c.136,000 refugees and last year received the most asylum applications in two decades. Despite this, expertise in migrant health is not widespread in general practice, with few comprehensive toolkits available to support crucial initial health assessments of new arrivals. Description of the problem: A large influx of Afghan refugees entered the UK in autumn 2021. In London, primary care practitioners quickly identified a lack of readily accessible, comprehensive guidance to support them in conducting health assessments for arrivals with a complex range of needs. This was compounded by many in primary care having little or no experience of migrant health.

Results:
To address this gap in advice on conducting initial health assessments, a bespoke toolkit was created. The toolkit consolidated advice from a range of partners and resources: the UK Afghan migrant health guide, clinicians with humanitarian experience, front-line practitioners, Doctors of the World, and those leading on the health and public health response. The toolkit ensured greater consistency in the nature and content of assessments, considered not only primary needs but also broader wellbeing, and was responsive to both anticipated and known health priorities.

Lessons:
The initial health assessment toolkit for Afghan migrants was well received by frontline staff and has implications for international practice in other areas providing similar health support. The toolkit and associated supporting information has formed a template that can be rapidly adapted to suit emerging needs, as has been done for new arrivals from Ukraine. This work has fed into best practice by the UK National Asylum Steering Group and is to be a case study for a WHO project on country-specific health assessments.

Key messages:
The toolkit is a proof of concept for partnership working towards holistic initial health assessments of new migrants in primary care, bringing together best evidence and pragmatic practice. This work has implications for other countries experiencing similar trends in migration and providing health support to an increasing number of new refugees.

Background:
The last two decades saw an extensive effort to design and implement integrated and multidimensional healthcare evaluation systems in high-income countries. However, in low/ middle-income countries, few experiences of such systems implementation have been reported in the scientific literature. We developed and piloted an innovative tool to assess the performance of health services provision for communicable diseases in three African countries.

Methods:
A total of 42 indicators, 14 per each communicable disease care pathway (Tuberculosis, Gastroenteritis, and HIV/AIDS), were developed. A sub-set of 23 indicators was included in the evaluation process. The indicators assessed four care phases: prevention, diagnosis, treatment, and outcome. All indicators were calculated for the period 2017-2019, while performance evaluation was performed for 2019. The analysis involved four health districts and their relative hospitals in Ethiopia, Tanzania, and Uganda. Results: Substantial variability was observed over time and across the four different districts. In the TB pathway, the majority of indicators scored below the standards and below-average performance was mainly reported for prevention and diagnosis phases. Along the Gastroenteritis pathway, excellent performance was instead evaluated for most indicators and the highest scores were reported in prevention and treatment phases. The HIV/AIDS pathway indicators related to screening and outcome phases were below the average score, while good or excellent performance was registered within the treatment phase.

Conclusions:
The bottom-up approach and stakeholders' engagement increased local ownership of the process and the likelihood that findings will inform health services performance and quality of care. Despite the intrinsic limitations of data sources, this framework may contribute to promoting good governance, performance evaluation and accountability in settings characterised by multiple healthcare service providers.

Key messages:
A successful experience in developing and implementing a communicable diseases performance evaluation systems in three sub-Saharan African countries using a bottom-up approach.
The communicable diseases performance evaluation tool helped the data sharing between local healthcare providers and the development of competencies in data collection, analysis and interpretation.

Background and aims:
The PM air pollution is a serious concern in northern Moravia in the Czech Republic. The aim is to evaluate the risk of acute hospital admissions for cardiovascular and respiratory causes with the use of the Geographic information system (GIS).

Methods:
The data on acute hospital admissions for cardiovascular (I00-99 according to ICD-10) and respiratory (J00-99) causes was assigned based on the information on residence to 77 geographical units (601,299 inhabitants). The annual concentrations of PM2.5 in the period 2013-2019 were assigned to this units according to the respective concentration iso-shapes (step 2 mg.m-3, concentrations 29 to ! 38 mg.m-3). The Incidence Rate Ratio (IRR) and 95% confidence interval (CI) was calculated for each concentration category. The incidence in the first category with the lowest PM2.5 concentrations ( 29 mg.m-3) was chosen the reference category. The statistical analyses were performed using the SW STATA v.15. Results: About a half of population (56%) in the year 2013 belonged into the PM2.5 category 34-35 mg.m-3, 26 thousand of inhabitants (4%) live in the PM2.5 concentrations !38 mg.m-3. During the analysed period the average concentration values decreased from 30.8 to 21.4 mg.m-3. A statistically significant risk of the acute hospitalization for cardiovascular causes was identified in the categories 36 mg.m-3, in the highest interval of PM2.5 the IRR values were 2-3-fold higher comparing with the reference category. As for respiratory causes, the trend is similar, but the statistically significant risk was found already from the interval 34-35 mg.m-3.

Conclusions:
With increasing concentrations, the risk of both acute cardiovascular, and respiratory hospitalizations increased. This presentation was supported by the project TH03030195 of the Technology Agency of the Czech Republic and the project Healthy Aging in the Industrial Environment CZ.02.1.01/0.0/ 0.0/16_019/0000798 (HAIE).

Key messages:
A statistically significant increase of the IRR for acute cardiovascular and respiratory hospitalizations was found at PM2.5 concentrations 34 mg.m-3 compared to the reference category 29 mg.m-3. Average annual PM2.5 concentration decreased from 30.8 to 21.4 mg.m-3 during the followed period and also the risk of acute hospitalization from cardiovascular and respiratory causes decreased.

Background:
Child mental health problems are considered the second highest cause of burden of disease in Europe and the Americas. Children's own opinions and experiences are pivotal in addressing these problems. However, including young children as active informants in health research and practice not only requires a well-trained and highly qualified workforce, but also valid methods that enhance and support children's selfexpression. The aim was to investigate preschool aged children's experiences in two health and welfare contexts using the interactive computer-assisted interview In My Shoes (IMS).

Methods:
Interviews were conducted using IMS in three studies encompassing 43 children aged 3-6 years old. The setting for the first and second study was Child Health Centres and the third setting was families entering the Triple P group parenting programme. Qualitative content analysis was performed.

Results:
The IMS interview aided preschool aged children to report on the factual, emotional and physical aspects of their experiences within a health care context. In addition, IMS helped young children verbalise unique information on negative interplay within their families, especially experiences of negative parenting including verbal and physical child abuse. The successes with IMS are likely related to the structured and systematic approach, that it is pictorial-based and emotion-focused, as well as the interactive, collaborative and triadic conversation between the child, the interviewer and the computer.

Conclusions:
The interactive computer-assisted interview IMS, is a suitable and valid method for aiding young children to provide unique and extensive information about different aspects of their experiences and lives. We urge professionals and researchers to systematically include the young children's own perspectives to better tailor and evaluate interventions on all levels to improve children's health and wellbeing. Key messages: Young children's own perspectives on their health and wellbeing are pivotal to better tailor and evaluate interventions.
The interactive computer-assisted interview In My Shoes is a suitable and valid method to capture children's voices.