Factors Determining Quality of Care in Family Planning Services in Africa: A Systematic Review of Mixed Evidence.

BACKGROUND: Improving use of family planning services is key to improving maternal health in Africa, and provision of quality of care in family planning services is critical to support higher levels of contraceptive uptake. The objective of this systematic review was to synthesize the available evidence on factors determining the quality of care in family planning services in Africa. METHODS: Quantitative and qualitative studies undertaken in Africa, published in English, in grey and commercial literature, between 1990 and 2015 were considered. Methodological quality of included studies was assessed using standardized tools. Findings from the quantitative studies were summarized using narrative and tables. Client satisfaction was used to assess the quality of care in family planning services in the quantitative component of the review. Meta-aggregation was used to synthesize the qualitative study findings. RESULTS: From 4334 records, 11 studies (eight quantitative, three qualitative) met the review eligibility criteria. The review found that quality of care was influenced by client, provider and facility factors, and structural and process aspects of the facilities. Client's waiting time, provider competency, provision/prescription of injectable methods, maintaining privacy and confidentiality were the most commonly identified process factors. The quality of stock inventory was the most commonly identified structural factor. The quality of care was also positively associated with privately-owned facilities. The qualitative synthesis revealed additional factors including access related factors such as 'pre-requisites to be fulfilled by the clients and cost of services, provider workload, and providers' behaviour. CONCLUSION: There is limited evidence on factors determining quality of care in family planning services in Africa that shows quality of care is influenced by multiple factors. The evidence suggests that lowering access barriers and avoiding unnecessary pre-requisites for taking contraceptive methods are important to improve the quality of care in family planning services. Strategies to improve provider behavior and competency are important. Moreover, strategies that minimize client waiting time and ensure client confidentiality should be implemented to ensure quality of care in family planning services. However, no strong evidence based conclusions and recommendations may be drawn from the evidence. Future studies are needed to identify the most important factors associated with quality of care in family planning services in a wider range of African countries.

Effectiveness of offloading methods in preventing primary diabetic foot ulcers in adults with diabetes: a systematic review.

BACKGROUND: The incidence of foot ulceration related to diabetes is increasing. Many foot care professionals recommend offloading measures as part of management strategies for modulating excess pressure to prevent development of diabetic foot ulcers (DFUs). These measures may include padding, insoles/orthotic devices and footwear. There is a lack of evidence-based guidance on the effectiveness of the different offloading options for preventing primary ulceration in those with diabetes. OBJECTIVES: To identify, critically appraise and synthesize the best available evidence on methods of offloading to prevent the development, and reduce the risk, of primary foot ulceration in adults with diabetes.The question addressed by the review was: what is the effectiveness of methods of offloading in preventing primary DFUs in adults with diabetes? INCLUSION CRITERIA TYPES OF PARTICIPANTS: Adults 18 years and older with diabetes mellitus, regardless of age, gender, ethnicity, duration or type of diabetes, with no history of DFUs and in any clinical setting will be included. TYPES OF INTERVENTIONS AND COMPARATORS: Interventions will include all external methods of offloading. All comparators will be considered. Studies that utilize interventions not considered usual practice in the prevention of DFUs will be excluded. OUTCOMES: The primary outcome will be primary foot ulceration. The secondary outcome will be indications of changes in plantar pressure. TYPES OF STUDIES: This review will consider all quantitative study designs. SEARCH STRATEGY: A three-step strategy for published and unpublished literature will be used. Fourteen databases will be searched for studies in English up to November 2013. DATA EXTRACTION: The JBI-MAStARI extraction tool was used to extract relevant data. DATA SYNTHESIS: Results were summarized using narrative and tables. RESULTS: Three studies which examined the effectiveness of four different offloading interventions met the inclusion criteria. There is limited evidence that use of a footwear system (prototype shoe plus polyurethane or cork insole) may prevent a break in the skin; use of customized rigid orthotic devices may contribute to a reduction in the grade and number of calluses; and a manufactured shoe plus customized insole may reduce plantar pressure and therefore reduce the potential risk of skin ulceration. CONCLUSION: There is limited and low-quality evidence that in a population of adults with diabetes with no history of DFU, the use of footwear with customized or prefabricated orthotic devices may provide some reduction in plantar pressure and therefore help to prevent a primary DFU. There is a lack of evidence on the relative effectiveness of different offloading options.

The effectiveness of surgical versus conservative treatment for symptomatic unilateral spondylolysis of the lumbar spine in athletes: a systematic review.

BACKGROUND: Spondylolysis is a common cause of low back pain in athletes. Historically, spondylolysis injuries were thought to be mostly bilateral; however advances in lumbar spine imaging have shown that in certain athlete groups, unilateral spondylolysis is highly prevalent. It remains unclear whether athletes with unilateral spondylolysis who undergo surgical repair are able to return to sports as effectively or faster than if they had conservative treatment. OBJECTIVES: To determine the effectiveness of surgical fixation performed after a trial period of conservative management, compared to the effectiveness of conservative management only for unilateral spondylolysis in athletes. TYPES OF PARTICIPANTS:   Athletes with symptomatic unilateral spondylolysis of the lumbar spine.  Types of intervention(s):  Surgical interventions which attempted a direct repair of the pars interarticularis, compared to conservative management.  Types of studies:  Experimental and epidemiological study designs were considered for inclusion. The majority of the studies reviewed consisted of descriptive epidemiological study designs including case series, individual case reports and descriptive cross sectional studies.  Types of outcomes:  The primary outcome of interest in this review was the ability to return to sport. The effectiveness of surgery on pain and overall function were secondary outcomes of interest. SEARCH STRATEGY: A three-step search strategy that aimed to find both published and unpublished studies was utilized. The search was limited to studies published in the English language between 1 January 1970 and 1 September 2013. METHODOLOGICAL QUALITY: The studies were critically appraised using one of the standardized critical appraisal instruments from The Joanna Briggs Institute. DATA COLLECTION: Details describing each study and results on effectiveness in promoting the outcomes of interest were extracted from papers included in the review using the standardized data extraction tool from The Joanna Briggs Institute. DATA SYNTHESIS: Due to heterogeneity in the included studies, the results for similar outcome measures were not pooled in statistical meta-analysis. A narrative and tabular format was used to synthesize the results of identified and included studies. RESULTS: Five studies reporting results for the outcomes of interest were critically appraised and included in the review. One study was a quasi-experimental design, while the other four were case series studies. Due to the paucity of data, studies were included regardless of whether their participants were exclusively athletes with unilateral spondylolysis or adults (athletes and non-athletes) with unilateral and bilateral spondylolysis. Sub-group analysis was used to distinguish the findings for the main participant group of interest, namely athletes with unilateral spondylolysis. CONCLUSIONS: The limited evidence on the effectiveness of surgical treatment versus conservative treatment for unilateral spondylolysis in athletes does not allow any conclusions to be drawn about the relative effectiveness of surgery versus conservative treatment for facilitating rapid return to sport or a high level of post injury sporting level/performance. It does suggest, however, that for adult athletes for whom conservative treatment has not been successful, surgery is likely to enable return to sport, reduce pain and promote overall function.