Structural Quality of Services and Use of Family Planning Services in Primary Health Care Facilities in Ethiopia. How Do Public and Private Facilities Compare?

BACKGROUND: Family planning (FP) is among the important interventions that reduce maternal mortality. Poor quality FP service is associated with lower services utilisation, in turn undermining the efforts to address maternal mortality. There is currently little research on the quality of FP services in the private sector in Ethiopia, and how it compares to FP services in public facilities. METHODS: A secondary data analysis of two national surveys, Ethiopia Services Provision Assessment Plus Survey 2014 and Ethiopian Demographic and Health Survey 2016, was conducted. Data from 1094 (139 private, 955 public) health facilities were analysed. In total, 3696 women were included in the comparison of users' characteristics. Logistic regression was conducted. Facility type (public vs. private) was the key exposure of interest. RESULTS: The private facilities were less likely to have implants (Adjusted Odds Ratio (AOR) = 0.06; 95% Confidence Interval (CI): 0.03, 0.12), trained FP providers (AOR = 0.23; 95% CI: 0.14, 0.41) and FP guidelines/protocols (AOR = 0.33; 95% CI: 0.19, 0.54) than public facilities but were more likely to have functional cell phones (AOR = 8.20; 95% CI: 4.95, 13.59) and water supply (AOR = 3.37; 95% CI: 1.72, 6.59). CONCLUSION: This study highlights the need for strengthening both private and public facilities for public-private partnerships to contribute to increased FP use and better health outcomes.

Assessing the quality of health research from an Indigenous perspective: the Aboriginal and Torres Strait Islander quality appraisal tool.

BACKGROUND: The lack of attention to Indigenous epistemologies and, more broadly, Indigenous values in primary research, is mirrored in the standardised critical appraisal tools used to guide evidence-based practice and systematic reviews and meta-syntheses. These critical appraisal tools offer no guidance on how validity or contextual relevance should be assessed for Indigenous populations and cultural contexts. Failure to tailor the research questions, design, analysis, dissemination and knowledge translation to capture understandings that are specific to Indigenous peoples results in research of limited acceptability and benefit and potentially harms Indigenous peoples. A specific Aboriginal and Torres Strait Islander Quality Appraisal Tool is needed to address this gap. METHOD: The Aboriginal and Torres Strait Islander Quality Appraisal Tool (QAT) was developed using a modified Nominal Group and Delphi Techniques and the tool's validity, reliability, and feasibility were assessed over three stages of independent piloting. National and international research guidelines were used as points of reference. Piloting of the Aboriginal and Torres Strait Islander QAT with Aboriginal and Torres Strait Islander and non-Indigenous experts led to refinement of the tool. RESULTS: The Aboriginal and Torres Strait Islander QAT consists of 14 questions that assess the quality of health research from an Aboriginal and Torres Strait Islander perspective. The questions encompass setting appropriate research questions; community engagement and consultation; research leadership and governance; community protocols; intellectual and cultural property rights; the collection and management of research material; Indigenous research paradigms; a strength-based approach to research; the translation of findings into policy and practice; benefits to participants and communities involved; and capacity strengthening and two-way learning. Outcomes from the assessment of the tool's validity, reliability, and feasibility were overall positive. CONCLUSION: This is the first tool to appraise research quality from the perspective of Indigenous peoples. Through the uptake of the Aboriginal and Torres Strait Islander QAT we hope to improve the quality and transparency of research with Aboriginal and Torres Strait Islander peoples, with the potential for greater improvements in Aboriginal and Torres Strait Islander health and wellbeing.

Healthcare providers' perspectives on use of the national guideline for family planning services in Amhara Region, Ethiopia: a qualitative study.

OBJECTIVE: To explore healthcare providers' views on barriers to and facilitators of use of the national family planning (FP) guideline for FP services in Amhara Region, Ethiopia. DESIGN: Qualitative study. SETTING: Nine health facilities including two hospitals, five health centres and two health posts in Amhara Region, Northwest Ethiopia. PARTICIPANTS: Twenty-one healthcare providers working in the provision of FP services in Amhara Region. PRIMARY AND SECONDARY OUTCOME MEASURES: Semistructured interviews were conducted to understand healthcare providers' views on barriers to and facilitators of the FP guideline use in the selected FP services. RESULTS: While the healthcare providers' views point to a few facilitators that promote use of the guideline, more barriers were identified. The barriers included: lack of knowledge about the guideline's existence, purpose and quality, healthcare providers' personal religious beliefs, reliance on prior knowledge and tradition rather than protocols and guidelines, lack of availability or insufficient access to the guideline and inadequate training on how to use the guideline. Facilitators for the guideline use were ready access to the guideline, convenience and ease of implementation and incentives. CONCLUSIONS: While development of the guideline is an important initiative by the Ethiopian government for improving quality of care in FP services, continued use of this resource by all healthcare providers requires planning to promote facilitating factors and address barriers to use of the FP guideline. Training that includes a discussion about healthcare providers' beliefs and traditional practices as well as other factors that reduce guideline use and increasing the sufficient number of guideline copies available at the local level, as well as translation of the guideline into local language are important to support provision of quality care in FP services.

What Indigenous Australian clients value about primary health care: a systematic review of qualitative evidence.

OBJECTIVE: To synthesise client perceptions of the unique characteristics and value of care provided in Aboriginal Community Controlled Health Organisations (ACCHOs) compared to mainstream/general practitioner services, and implications for improving access to quality, appropriate primary health care for Indigenous Australians. METHOD: Standardised systematic review methods with modification informed by ethical and methodological considerations in research involving Indigenous Australians. RESULTS: Perceived unique valued characteristics of ACCHOs were: 1) accessibility, facilitated by ACCHOs welcoming social spaces and additional services; 2) culturally safe care; and 3) appropriate care, responsive to holistic needs. CONCLUSION: Provider-client relationships characterised by shared understanding of clients' needs, Indigenous staff, and relationships between clients who share the same culture, are central to ACCHO clients' perceptions of ACCHOs' unique value. The client perceptions provide insights about how ACCHOs address socio-economic factors that contribute to high levels of chronic disease in Indigenous communities, why mainstream PHC provider care cannot substitute for ACCHO care, and how to improve accessibility and quality of care in mainstream providers. Implications for public health: To increase utilisation of PHC services in Indigenous Australian communities, and help close the gaps between the health status of Indigenous and non-Indigenous Australians, Indigenous community leaders and Australian governments should prioritise implementing effective initiatives to support quality health care provision by ACCHOs.

Client and facility level determinants of quality of care in family planning services in Ethiopia: Multilevel modelling.

INTRODUCTION: Over the last two decades, while contraceptive use has improved in Ethiopia, the contraceptive prevalence rate remains low. In addition to socio-demographic and cultural factors, the quality of care in Family Planning (FP) services is an important determining factor of FP utilization. However, little research exists on the determinants of quality of care in FP services in Ethiopia. This study aims to identify the client and facility level determinants of quality of care in FP services in Ethiopia. METHODS: This study was based on the first Ethiopian Services Provision Assessment Plus (ESPA+) survey conducted in 2014. A total of 1247 clients nested in 374 health facilities were included in the analysis. Multilevel mixed-effects logistic regression modelling was conducted. The outcome variable, client satisfaction, was created using polychoric principal component analysis using eleven facets that reflect client satisfaction. RESULTS: The results showed that both client-level and facility-level factors were associated with quality of care in FP services in Ethiopia. At the client-level; provision of information on potential side effects of contraceptive method (AOR = 5.22, 95% CI: 2.13-12.80), and number of history and physical assessments (AOR = 1.19, 95% CI: 1.03-1.34) were positively associated with client satisfaction, whereas waiting times of 30 minutes to two hours (AOR = 0.11, 95% CI: 0.03-0.33) was negatively associated with client satisfaction. At the facility-level; urban location (AOR = 4.61, 95% CI: 1.04-20.58), and availability of FP guidelines/protocols for providers (AOR = 4.90, 95% CI: 1.19-20.19) had positive significant effect on client satisfaction. CONCLUSION: Quality improvement programs in FP services in Ethiopia should focus on shortening waiting times and provision of information about the potential side effects of contraceptive methods. It is also important to improve health providers' skills in thorough client history taking and physical assessment. Further distribution and implementation of best practice guidelines for providers working in the FP services must be a priority.

Prevalence and characteristics of overweight and obesity in indigenous Australian children: A systematic review.

Evidence-based profiling of obesity and overweight in Indigenous Australian children has been poor. This study systematically reviewed evidence of the prevalence and patterns of obesity/overweight, with respect to gender, age, remoteness, and birth weight, in Indigenous Australian children, 0-18 years (PROSPERO CRD42014007626). Study quality and risk of bias were assessed. Twenty-five publications (21 studies) met inclusion criteria, with large variations in prevalence for obesity or overweight (11 to 54%) reported. A high degree of heterogeneity in study design was observed, few studies (6/21) were representative of the target population, and few appropriately recruited Indigenous children (8/21). Variability in study design, conduct, and small sample sizes mean that it is not possible to derive a single estimate for prevalence although two high-quality studies indicate at least one in four Indigenous Australian children are overweight or obese. Four of six studies reporting on gender, found overweight/obesity higher in girls and eight studies reporting on overweight/obesity by age suggest prevalence increases with age with one high quality large national study reporting total overweight/obesity as 22.4% of children aged 2-4 years, 27.5% of those aged 5-9, 38.5% aged 10-14, and 36.3% aged 15-17. Three of four studies, reporting obesity/overweight by region, found lower rates for children living in more remote areas than urban areas.

Factors determining quality of care in family planning services in Africa: a systematic review protocol.

REVIEW OBJECTIVE AND QUESTIONS: The objective of this systematic review is to identify and synthesize the best available quantitative and qualitative evidence to understand the factors determining quality of care in family planning services in Africa.The review question for the quantitative component of the review is:What factors, including facility, provider and client characteristics, are associated with quality of care in family planning services in Africa?The review question for the qualitative component of the review is:What are client and provider experiences and/or perceptions of factors that affect quality of care in family planning services in Africa?

The effectiveness of ayurvedic oil-based nasal instillation (Nasya) medicines in the treatment of facial paralysis (Ardita): a systematic review.

BACKGROUND: Ardita (facial paralysis) is a medical condition that disfigures or distorts the facial appearance of the sufferer causing facial asymmetry and malfunction. Ardita patients may benefit from considering alternative treatments such as Ayurveda, including Taila Nasya (nasal instillation of medicated oil). OBJECTIVES: To synthesize the best available evidence on the effectiveness of different Nasya oils in the treatment of Ardita. INCLUSION CRITERIA TYPES OF PARTICIPANTS: Studies conducted on adult sufferers (18-70 years) of Ardita (chronic or acute) in any setting were considered. Studies including participants who were pregnant or suffered allergic rhinitis, fever, intracranial tumor/hemorrhage and bilateral facial palsy were excluded. INTERVENTION(S)/COMPARATOR(S): Standalone treatment of Nasya (at all dosages and frequencies) compared to Nasya in combination with other Ayurvedic treatments was considered. Comparisons between different interventions including Taila Nasya alone, Taila Nasya in combination with other Ayurvedic interventions and Ayurvedic interventions that did not include Taila Nasya were also considered. OUTCOMES AND MEASURES: Changes in Ardita symptoms, including facial distortion, speech disorders and facial pain, were measured. TYPES OF STUDIES: All quantitative study designs (experimental, quasi-experimental and observational) were considered. SEARCH STRATEGY: Relevant studies were identified following a comprehensive literature search. References provided within these key studies identified additional resources. Indian universities were also contacted for results of Ardita studies undertaken in their institutions.A three-step search strategy aimed to find studies of published and unpublished studies was undertaken. Studies published in the English language were considered for inclusion, irrespective of publication date/year. Following an initial limited search of MEDLINE and CINAHL, the text words contained in the title and abstract, and of the index terms used to describe each articles were analyzed. From the identified keywords and index terms, searches were undertaken across all relevant databases such as PubMed, CINHAL, Cochrane (CENTRAL), Scopus, Centre for Review and Dissemination databases, Turning Research into Practice (TRIP), EMBASE, EBM Reviews, DHARA, Google Scholar, MedNar and ProQuest Dissertations. Finally, reference lists of identified theses and articles were searched for additional studies. Universities and website operators related to Ayurvedic research in India were contacted, including the National Institute of Ayurveda for relevant studies. Besides this, the University of Adelaide librarian was contacted to retrieve those studies identified in the reference lists of theses and articles. METHODOLOGICAL QUALITY: Studies were critically assessed by the review author and a secondary reviewer prior to inclusion in the review using the standardized critical appraisal instrument from the Joanna Briggs Institute. DATA EXTRACTION: Data was extracted by the primary reviewer using the standardized data extraction tool from the Joanna Briggs Institute. DATA SYNTHESIS: Different interventions and comparators across studies precluded meta-analysis. Narrative synthesis was performed. RESULTS: Only two pseudo randomized studies with a small number of participants met inclusion criteria and were included in the review. One study with 20 participants, divided equally into two groups compared the effectiveness of two nasal instillations in alleviating four Ardita symptoms. The second study of 15 participants each in two groups compared the effectiveness of nasal instillation with placement of medicated oil on the head on seven Ardita symptoms. Observational measurements of Ardita symptoms were graded as Mild, Moderate or Marked at baseline and after one month. The study conducted on 30 participants using Nasya intervention showed participants had better relief from the symptoms of facial pain, speech disorder and earache within the range of 78.2% to 90.9%, graded as Marked. Along with statistical data available in the studies, this review found low levels of evidence favoring Taila Nasya intervention. The review did not include any studies examining effectiveness of Nasya compared to conventional treatment for Ardita. CONCLUSIONS: This review presents extremely limited evidence from only two small experimental studies that administration of Nasya oil alone may provide some relief from Ardita symptoms of facial distortion, speech disorder, inability to shut eyelids/upward eye rolling and dribbling of saliva in adult patients. No strong conclusions may be drawn from the evidence included in the review due to the limited number of studies, limited number of participants and poor quality of studies. IMPLICATIONS FOR PRACTICE: Practitioners should advice Ardita patients that there is extremely limited evidence suggesting the potential effectiveness of Nasya oils alone or Nasya in conjunction with other Ayurvedic treatments in managing symptoms. However, given the absence of a strong evidence base, practitioners should be guided by clinical wisdom and patient preference. IMPLICATIONS FOR RESEARCH: Well controlled clinical trials comparing standalone Nasya therapy to other Ayurvedic treatments and/or conventional medicine for Ardita symptoms need to be conducted to examine the relative effectiveness of different Nasya oils in treating Ardita.

Systematic review to inform prevention and management of chronic disease for Indigenous Australians: overview and priorities.

OBJECTIVE: To describe the main characteristics of systematic reviews addressing questions of chronic disease and related risk factors for Indigenous Australians. METHODS: We searched databases for systematic reviews meeting inclusion criteria. Two reviewers assessed quality and extracted characteristics using pre-defined tools. RESULTS: We identified 14 systematic reviews. Seven synthesised evidence about health intervention effectiveness; four addressed chronic disease or risk factor prevalence; and six conducted critical appraisal as per current best practice. Only three reported steps to align the review with standards for ethical research with Indigenous Australians and/or capture Indigenous-specific knowledge. Most called for more high-quality research. CONCLUSION: Systematic review is an under-utilised method for gathering evidence to inform chronic disease prevention and management for Indigenous Australians. Relevance of future systematic reviews could be improved by: 1) aligning questions with community priorities as well as decision maker needs; 2) involvement of, and leadership by, Indigenous researchers with relevant cultural and contextual knowledge; iii) use of critical appraisal tools that include traditional risk of bias assessment criteria and criteria that reflect Indigenous standards of appropriate research. IMPLICATIONS: Systematic review method guidance, tools and reporting standards are required to ensure alignment with ethical obligations and promote rigor and relevance.

Daily 2% chlorhexidine gluconate bath wash in a tertiary adult intensive care and high dependency units to reduce risk of hospital acquired multi resistant organisms: a best practice implementation project.

BACKGROUND: There is growing evidence that the incidence of hospital acquired multi resistant organisms are increasing worldwide. Intensive care patients are particularly prone to hospital-acquired infections. In an effort to combat increasing nosocomial infections rates within the intensive care/high dependency unit setting, Canberra Hospital has implemented a daily 2% chlorhexidine gluconate bath wash in combination as part of a best practice policy to reduce hospital acquired multi resistant organism rates of colonization. This project focused on auditing the extent to which the protocol was implemented and on promoting its implementation. OBJECTIVES: The primary aim of this evidence implementation project was to promote best practice in the use of 2% chlorhexidine gluconate body cleansing in the Canberra Hospital intensive care unit and high dependency unit settings. A secondary aim was to improve intensive care/high dependency unit patient outcomes and resource utilization. METHODS: The project used the Joanna Briggs Institute's Practical Application of Clinical Evidence System and Getting Research into Practice audit tools for promoting change in 2% chlorhexidine gluconate wash health practice. A baseline audit was conducted followed by a three-prong education approach strategy targeted at clinicians and finalized using a follow-up audit. RESULTS: There was an improvement in best practice for all criteria monitored in the follow-up audit compared to the initial audit. The most significant improvement was education and allergy assessment with 90% and 46% improvements respectively. Wipe application compliance improved by 28% to 55%, suggesting a need for continual education. Minor decreases in compliance were also noted in allergy documentation and application technique by 2% and 7% respectively. CONCLUSIONS: The project was successful in increasing knowledge surrounding 2% chlorhexidine gluconate wash administration and has provided a future direction for sustaining evidence-based practice change. Further audits will need to be carried out in order to maintain the practice change and support sustained implementation of the best practice protocol.

Carers' experiences when the person for whom they have been caring enters a residential aged care facility permanently: a systematic review.

BACKGROUND: Primary research, including qualitative research, as well as experts working in social services and aged care have identified the mixed feelings carers experience when the person they have been caring for is admitted into a residential aged care facility permanently. They have raised the importance of understanding these experiences as a means to implementing policies and programs that enhance carers' well-being. This systematic review was motivated by the need to use evidence to inform effective and feasible interventions to support carers, and the absence of a systematic review synthesizing the qualitative evidence on how carers experience this transition. OBJECTIVES: The objective of this qualitative systematic review was to identify and synthesize the evidence on the experiences of carers of older people when the person they had been providing care for is admitted permanently into a residential aged care facility, and to draw recommendations from the synthesis of the evidence on these experiences to enhance policy and programming aimed at supporting affected caregivers. TYPES OF PARTICIPANTS: All carers of people who had experienced the person they had been caring for at home being moved into a residential aged care facility permanently. PHENOMENA OF INTEREST: Experiences of the caregiver of the older person when the person they have been caring for at home is admitted into a residential aged care facility permanently. TYPES OF STUDIES: The review considered qualitative studies, including but not limited to designs such as phenomenology, grounded theory, ethnography and action research. TYPES OF OUTCOMES: The outcomes are in the form of synthesized findings pertaining to carers' experiences when the person they have been caring for is admitted into a residential aged care facility permanently. SEARCH STRATEGY: A comprehensive search of leading databases which are sources of qualitative published and unpublished studies was conducted between 18 September 2013 and 10 November 2013. The search considered studies reported in English and published from the database inception to 10 November 2013. METHODOLOGICAL QUALITY: Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using the Joanna Briggs Institute Qualitative Assessment and Review Instrument. DATA EXTRACTION: Data were extracted from identified papers using the standardized data extraction tool from the Joanna Briggs Institute Qualitative Assessment and Review Instrument. The data extracted included descriptive details about the phenomena of interest, populations and study methods. DATA SYNTHESIS: The Joanna Briggs Institute meta-aggregative approach for synthesizing qualitative evidence was used. Research findings were pooled using the Joanna Briggs Institute Qualitative Assessment and Review Instrument. Study findings that were supported by the data in primary studies were organized into categories on the basis of similarity of meaning. These categories were then subjected to a meta-synthesis to produce a set of synthesized findings. RESULTS: Fourteen studies matched the inclusion criteria and were included in the review. From these 14 studies a total of 71 study findings about how carers experience the transition when the person they have been caring for is TRUNCATED AT 500 WORDS.

Conducting systematic reviews of economic evaluations.

BACKGROUND: In 2012, a working group was established to review and enhance the Joanna Briggs Institute (JBI) guidance for conducting systematic review of evidence from economic evaluations addressing a question(s) about health intervention cost-effectiveness. OBJECTIVES: The objective is to present the outcomes of the working group. METHODS: The group conducted three activities to inform the new guidance: review of literature on the utility/futility of systematic reviews of economic evaluations and consideration of its implications for updating the existing methodology; assessment of the critical appraisal tool in the existing guidance against criteria that promotes validity in economic evaluation research and two other commonly used tools; and a workshop. RESULTS: The debate in the literature on the limitations/value of systematic review of economic evidence cautions that systematic reviews of economic evaluation evidence are unlikely to generate one size fits all answers to questions about the cost-effectiveness of interventions and their comparators. Informed by this finding, the working group adjusted the framing of the objectives definition in the existing JBI methodology. The shift is away from defining the objective as to determine one cost-effectiveness measure toward summarizing study estimates of cost-effectiveness and informed by consideration of the included study characteristics (patient, setting, intervention component, etc.), identifying conditions conducive to lowering costs and maximizing health benefits. The existing critical appraisal tool was included in the new guidance. The new guidance includes the recommendation that a tool designed specifically for the purpose of appraising model-based studies be used together with the generic appraisal tool for economic evaluations assessment to evaluate model-based evaluations. The guidance produced by the group offers reviewers guidance for each step of the systematic review process, which are the same steps followed in JBI reviews of other types of evidence. DISCUSSION: The updated JBI guidance will be useful for researchers wanting to synthesize evidence about economic questions, either as stand-alone reviews or part of comprehensive or mixed method evidence reviews. Although the updated methodology produced by the work of the working group has improved the JBI guidance for systematic reviews of economic evaluations, there are areas where further work is required. These include adjusting the critical appraisal tool to separate out questions addressing intervention cost and effectiveness measurement; providing more explicit guidance for assessing generalizability of findings; and offering a more robust method for evidence synthesis that facilitates achieving the more ambitious review objectives.

Health care worker hand hygiene in the pediatric special care unit at Mulago National Referral Hospital in Uganda: a best practice implementation project.

INTRODUCTION: The hands of a health care worker are a common vehicle of pathogen transmission in hospital settings. Health care worker hand hygiene is therefore critical for patients' well being. Whilst failure of health care workers to comply with the best hand hygiene practice is a problem in all health care settings, issues of lack of access to adequate cleaning equipment and in some cases even running water make practicing good hand hygiene particularly difficult in low-resource developing country settings. This study reports an audit and feedback project that focused on the hand hygiene of the health care worker in the pediatric special care unit of the Mulago National Referral Hospital, which is a low-resource setting in Uganda. OBJECTIVE: To improve hand hygiene among health care workers in the pediatric special care unit and thereby contribute to reducing transmission of health care worker-associated pathogens. METHODS: The Joanna Briggs Institute three-phase Practical Application of Clinical Evidence System audit and feedback tool for promoting evidence utilization and change in health care was used. In phase one of the project, stakeholders were engaged and seven evidence-based audit criteria were developed. A baseline audit was then conducted. In phase two, barriers underpinning areas of noncompliance found in the baseline audit were identified and three strategies - education, reminders and provision of hand cleaning equipment - were implemented to overcome them. In phase three, a follow-up audit was conducted. RESULTS: Compliance with best practice hygiene was found to be poor in the baseline audit for all but one of the audit criteria. Following the implementation of the strategies, hand hygiene improved. The compliance rate increased substantially across all criteria. Staff education achieved 100%, whilst criterion 4 increased to 70%. However, use of alcohol-based hand-rub for hand hygiene only improved to 66%, and for six of the seven audit criteria, compliance remained below 74%. CONCLUSION: The project provides another example of how audit can be used as a tool to improve health practice, even in a low-resource setting. At the same time, it showed how difficult it is to achieve compliance with best hand hygiene practice in a low-resource hospital. The project highlights the importance of continued education/awareness raising on the importance of good hand hygiene practice as well as investment in infrastructure and cleaning supplies for achieving and sustaining good hand hygiene among workers in a low-resource hospital setting. A key contribution of the project was the legacy it left in the form of knowledge about how to use audit and feedback as a tool to promote the best practice. A similar project has been implemented in the maternity ward at the hospital and further audits are planned.