Bounding systems: A qualitative study exploring healthcare coordination between the emergency youth shelter system and health system in Toronto, Canada.

BACKGROUND: Several youth staying at emergency youth shelters (EYSs) in Toronto experience poorly coordinated care for their health needs, as both the EYS and health systems operate largely in silos when coordinating care for this population. Understanding how each system is structurally and functionally bound in their healthcare coordination roles for youth experiencing homelessness (YEH) is a preliminary step to identify how healthcare coordination can be strengthened using a system thinking lens, particularly through the framework for transformative system change. METHODS: Forty-six documents, and twenty-four semi-structured interviews were analyzed to explore how the EYS and health systems are bound in their healthcare coordination roles. We continuously compared data collected from documents and interviews using constant comparative analysis to build a comprehensive understanding of each system's layers, and the niches (i.e., programs and activities), organizations and actors within these layers that contribute to the provision and coordination of healthcare for YEH, within and between these two systems. RESULTS: The EYS and health systems are governed by different ministries, have separate mandates, and therefore have distinct layers, niches, and organizations respective to coordinating healthcare for YEH. While neither system takes sole responsibility for this task, several government, research, and community-based efforts exist to strengthen healthcare coordination for this population, with some overlap between systems. Several organizations and actors within each system are collaborating to develop relevant frameworks, policies, and programs to strengthen healthcare coordination for YEH. Findings indicate that EYS staff play a more active role in coordinating care for YEH than health system staff. CONCLUSION: A vast network of organizations and actors within each system layer, work both in silos and collaboratively to coordinate health services for YEH. Efforts are being made to bridge the gap between systems to improve healthcare coordination, and thereby youths' health outcomes.

Where are the links? Using a causal loop diagram to assess interactions in healthcare coordination for youth experiencing homelessness in Toronto, Canada.

BACKGROUND: Youth experiencing homelessness (YEH) suffer from poorer physical and mental health outcomes than stably housed youth. Additionally, YEH are forced to navigate fragmented health and social service systems on their own, where they often get lost between systems when transitioning or post-discharge. Inevitably, YEH require support with health system navigation and healthcare coordination. The aim of this study is to understand interactions within and between the emergency youth shelter (EYS) and health systems that affect healthcare coordination for YEH in Toronto, Canada, and how these interactions can be targeted to improve healthcare coordination for YEH. METHODS: This study is part of a larger qualitative case study informed by the framework for transformative systems change. To understand interactions in healthcare coordination for YEH within and between the EYS and health systems, we developed a causal loop diagram (CLD) using in-depth interview data from 24 key informants at various levels of both systems. Open and focused codes developed during analysis using Charmaz's constructivist grounded theory methodology were re-analysed to identify key variables, and links between them to create the CLD. The CLD was then validated by six stakeholders through a stakeholder forum. RESULTS: The CLD illustrates six balancing and one reinforcing feedback loop in current healthcare coordination efforts within the EYS and health systems, respectively. Increasing EYS funding, building human resource capacity, strengthening inter and intra-systemic communication channels, and establishing strategic partnerships and formal referral pathways were identified among several other variables to be targeted to spiral positive change in healthcare coordination for YEH both within and between the EYS and health systems. CONCLUSIONS: The CLD provides a conceptual overview of the independent and integrated systems through which decision-makers can prioritize and guide interventions to strengthen healthcare coordination within and between the EYS and health systems. Overall, our research findings suggest that key variables such as streamlining communication and improving staff-youth relationships be prioritized, as each of these acts interdependently and influences YEH's access, quality and coordination of healthcare.

Where's the Disconnect? Exploring Pathways to Healthcare Coordinated for Youth Experiencing Homelessness in Toronto, Canada, Using Grounded Theory Methodology.

About 900 youth experiencing homelessness (YEH) reside at an emergency youth shelter (EYS) in Toronto on any given night. Several EYSs offer access to healthcare based on youths' needs, including access to primary care, and mental health and addictions support. However, youth also require healthcare from the broader health system, which is often challenging to navigate and access. Currently, little is known about healthcare coordination efforts between the EYS and health systems for YEH. Using grounded theory methodology, we interviewed 24 stakeholders and concurrently analyzed and compared data to explore pathways to healthcare coordinated for youth who reside at an EYS in Toronto. We also investigated fundamental parts (i.e., norms, resources, regulations, and operations) within the EYS and health systems that influence these pathways to healthcare using thematic analysis. A significant healthcare coordination gap was found between these two systems, typically when youth experience crises, often resulting in a recurring loop of transition and discharge between EYSs and hospitals. Several parts within each system act interdependently in hindering adequate healthcare coordination between the EYS and health systems. Incorporating training for system staff on how to effectively coordinate healthcare and work with homeless populations who have complex health needs, and rethinking information-sharing policies within circles of care are examples of how system parts can be targeted to improve healthcare coordination for YEH. Establishing multidisciplinary healthcare teams specialized to serve the complex needs of YEH may also improve healthcare coordination between systems, and access and quality of healthcare for this population.

Prevalence and Predictors of Intimate Partner Violence Among Married Women in Egypt.

Intimate partner violence (IPV) among married women of childbearing age can significantly enhance their risk of adverse health outcomes such as injury and disability, depression and anxiety, unwanted pregnancies, premature labor, complications with delivery, and perinatal and neonatal mortality. The objective of this study was to examine the prevalence and individual and societal factors associated with IPV among Egyptian women. Cross-sectional data on 12,205 ever-married women between the ages of 15 to 49 years were collected from the Egypt Demographic and Health Survey (EDHS). Data from the 2005 and 2014 EDHS were pooled and analyzed. Self-reported responses on violence by husbands were classified into physical, sexual, and emotional violence. The factors of association were quantified using logistic regression methods. The prevalence of experiencing any form of violence among ever-married women in Egypt was 29.4%. Overall, women reported experiencing physical, emotional, and sexual violence at 26.7%, 17.8%, and 4.6%, respectively. Women in the age group of 25 to 29 years had the highest odds (odds ratio [OR] = 1.539, 95% confidence interval [CI] = [1.327, 1.785]) of suffering from any form of IPV. Women residing in urban areas (OR = 1.149, 95% CI = [1.046, 1.262]), having only a primary-level education (OR = 1.756, 95% CI = [1.543, 1.999]), being followers of Islam (OR = 1.713, 95% CI = [1.379, 2.126]), and having husbands with no education (OR = 1.422, 95% CI = [1.263, 1.601]) reported having higher odds of experiencing any form of IPV. Nearly one third of married women of childbearing age are exposed to IPV of any form in Egypt. IPV intervention programs should pay special attention to the socioeconomically vulnerable segments of the population and promote educational status among men and women to curb the occurrence of IPV.

Promoting and delivering antenatal care in rural Jimma Zone, Ethiopia: a qualitative analysis of midwives' perceptions.

BACKGROUND: Despite improvements in recent years, Ethiopia faces a high burden of maternal morbidity and mortality. Antenatal care (ANC) may reduce maternal morbidity and mortality through the detection of pregnancy-related complications, and increased health facility-based deliveries. Midwives and community-based Health Extension Workers (HEWs) collaborate to promote and deliver ANC to women in these communities, but little research has been conducted on the professional working relationships between these two health providers. This study aims to generate a better understanding of the strength and quality of professional interaction between these two key actors, which is instrumental in improving healthcare performance, and thereby community health outcomes. METHODS: We conducted eleven in-depth interviews with midwives from three rural districts within Jimma Zone, Ethiopia (Gomma, Kersa, and Seka Chekorsa) as a part of the larger Safe Motherhood Project. Interviews explored midwives' perceptions of strengths and weaknesses in ANC provision, with a focus as well on their engagement with HEWs. Thematic content analysis using Atlas.ti software was used to analyse the data using an inductive approach. RESULTS: Midwives interacted with HEWs throughout three key aspects of ANC promotion and delivery: health promotion, community outreach, and provision of ANC services to women at the health centre and health posts. While HEWs had a larger role in promoting ANC services in the community, midwives functioned in a supervisory capacity and provided more clinical aspects of care. Midwives' ability to work with HEWs was hindered by shortages in human, material and financial resources, as well as infrastructure and training deficits. Nevertheless, midwives felt that closer collaboration with HEWs was worthwhile to enhance service provision. Improved communication channels, more professional training opportunities and better-defined roles and responsibilities were identified as ways to strengthen midwives' working relationships with HEWs. CONCLUSION: Enhancing the collaborative interactions between midwives and HEWs is important to increase the reach and impact of ANC services and improve maternal, newborn and child health outcomes more broadly. Steps to recognize and support this working relationship require multipronged approaches to address imminent training, resource and infrastructure deficits, as well as broader health system strengthening.

Knowledge and attitude of HIV/AIDS among women in Nigeria: a cross-sectional study.

Background: The Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS) epidemic is one of the world's most serious public health and social problems. Promoting knowledge and attitude towards HIV/AIDS is a key strategy to control the prevalence of this growing epidemic. This study aimed to measure knowledge and attitude about HIV/AIDS along with the factors of association Nigerian women. Methods: This is a cross-sectional study based on data from the 2013 Demographic Health Survey (DHS) conducted among community dwelling women in Nigeria. A set of 13 questions was identified relevant to knowledge and attitude about HIV/AIDS. Each correct answer was scored as 1 and wrong answer as '0'. Normality of the variables was examined using Shapiro-Wilks tests. The socioeconomic and community factors associated with HIV/AIDS knowledge and attitude were examined by linear regression with dummy variables model. Results: Means score (SD) on knowledge of transmission was 6.4 (2.0) and that for attitude was 2.1 (1.2). In the regression models, knowledge and attitude of HIV/AIDS were positively associated with survey years and respondents' age; geographical region was significantly associated with HIV/AIDS knowledge and attitude; rural respondents had significant reduction in knowledge [Exp(B)=0.86; 95% confidence interval (CI)=0.83-0.89] and positive attitude to HIV/AIDS [Exp(B)=0.91; 95% CI=0.89-0.93] compared with the urban counterpart, respectively. Conclusion: Findings of the present study suggested that women's knowledge and attitude about HIV/AIDS in Nigeria needs more attention to attain the global target to end its epidemics and other communicable diseases by 2030.

Assessing community (peer) researcher's experiences with conducting spirometry and being engaged in the 'Participatory Research in Ottawa: Management and Point-of-care for Tobacco-dependence' (PROMPT) project.

PLAIN SUMMARY: This article examines the overall experiences of community researchers in their involvement with the 'PROMPT' project for smoking cessation, which targeted community members who were homeless or at-risk for homelessness. More specifically, four community members, representing the study population were involved in the project as researchers. They were asked to complete surveys at both the beginning and end of each research training session to better understand their learning as it related to using a key instrument for this project, a spirometer, to measure project participants' lung function. Spirometry is typically performed by trained healthcare providers. Community researchers were also interviewed to explore what their experiences were like working as a researcher with their own at-risk community. Although the researchers felt that the training was sufficient, more research is needed to evaluate training effectiveness among community researchers in delivering acceptable quality lung function testing using a spirometer. Upon analyzing the small group discussion and survey results, we found that the community researchers had an overall positive experience with both the project, and the training that was provided to equip them with the knowledge, tools, and resources they needed to successfully work in a research project of this kind. They also faced challenges that are common in such community-based projects, such as the power differential between the researchers with a healthcare background and themselves who have lived experience with the issue at hand. ABSTRACT: Background The Ottawa Citizen Engagement and Action Model (OCEAM) used a Community Based Participatory Action Research (CBPAR) approach by involving the most at-risk urban population. Community (peer) researchers participated in every step of the study despite the multiple challenges. Objective To assess the community researchers' training and experiences in a CBPAR project, PROMPT: Participatory Research in Ottawa: Management and Point-of-care for Tobacco Dependence. Method Four community researchers were recruited, representative of the PROMPT project's target population with current or past poly-substance use; smoking tobacco; and/or being homeless or at-risk for homelessness. The community researchers participated in all phases of PROMPT, including study design, development of questionnaires, participant recruitment, administering consent forms and questionnaires, as well as hand-held spirometry after rigorous training. To assess their knowledge and comfort level with spirometry testing after standardized training, questionnaires were administered pre- and post-training. In turn, to assess their overall experience, interviews were conducted at the end of study completion. Results All community researchers underwent small-group training sessions including presentations, discussions and hands-on practice adapted from standardized training material prepared for health care professionals. Spirometry training was included in all sessions. Self-perceived knowledge and confidence in administering spirometry, as well as skill-testing score averages improved between the pre- and post-training questionnaires. Overall, all the community researchers had a fulfilling experience participating in the project. Conclusion Despite challenges, involving community researchers with lived experience is feasible, satisfying and productive even in the most marginalized populations. Standardized spirometry training of community researchers' representative of the PROMPT target population, with no healthcare educational background, was feasible and effective in improving knowledge, confidence and readiness to administer spirometry.

Improving Water, Sanitation and Hygiene Practices, and Housing Quality to Prevent Diarrhea among Under-Five Children in Nigeria.

Sub-Saharan Africa as a region accounts for the bulk of the global under-five mortality rate, to which diarrhea is major contributor. Millions of children die from diarrheal diseases each year and those who survive often do so facing suboptimal growth. Preventing the common pathways of transmission for diarrhea-causing pathogens, including improved water, sanitation, and hygiene (WASH) are regarded as the most cost-effective measures for tackling this life-threatening disease. This study aimed to quantitatively assess the quality of living arrangement and access to WASH, and their impact on diarrheal outcomes among under-five children in Nigeria. Methods: Data were collected from the 2013 Nigeria Demographic and Health survey (NDHS). Study participants included 28,596 mother-child pairs. Household construction material for wall, floor, and ceiling, access to electricity, and improved water and toilet, were included as the main explanatory variables. Data were analyzed using descriptive and multivariable regression methods. Results: The prevalence of diarrhea was 11.3% (95% CI = 10.2⁻12.6), with the rate being markedly higher in rural (67.3%) as compared to urban areas (32.7%). In the regression analysis, lacking access to improved toilet and water facilities were associated with 14% and 16% higher odds, respectively, of suffering from diarrhea as compared to those who had improved access. Conclusion: There is evidence of a weak, but statistically significant, relationship between the quality of living environment, including water and sanitation facilities, and diarrhea among under-five children in Nigeria. The study concludes that investing in living conditions and WASH may have potential benefits for child mortality prevention programs in the country.

Prevalence and determinants of terminated and unintended pregnancies among married women: analysis of pooled cross-sectional surveys in Nigeria.

BACKGROUND: Induced pregnancy termination and unintended pregnancy are two commonly occurring phenomena in the discipline of women's reproductive health. In the present study, we explored cross-sectional data pooled from three rounds of Nigeria Demographic and Health Survey (NDHS) to understand the trends of prevalence of pregnancy termination and unintended pregnancy as well as the interplay of various sociodemographic and economic factors whereby these health issues occur. METHODS: Study participants were 79 825 currently married women aged 15-49 years. Data were collected from NDHS conducted in 2003, 2008 and 2013. Outcome variables were self-reported history of pregnancy termination and unintended pregnancy for the last birth. Data were analysed using descriptive and multivariable logistic regression methods. RESULTS: Mean (±SD) age of the respondents was 28.7 years (±9.6). The overall prevalence of pregnancy termination and unintended pregnancy were about 11%. Older women had increase in the odds of terminated pregnancies, compared with women aged 15-19 years, while the converse was true for unintended pregnancy in the adjusted model. Educated women had significant higher odds of terminated and unintended pregnancies compared with women with no formal education. Women with higher wealth index were more likely to have unintended and terminated pregnancies after adjusting for other covariates. Remarkably, women who had unintended pregnancy were 1.47 times as likely to have terminated pregnancy compared with those who had no unintended pregnancy (OR=1.47; 95% CI 1.30 to 1.65). Experience of intimate partner violence had significant association with terminated and unintended pregnancies. CONCLUSION: The findings of this study showed that unintended and terminated pregnancies remain part of the issues to be addressed if the goal of ensuring healthy lives and promoting the well-being for all at all ages must be met. Stakeholders in Nigerian healthcare system should protect the lives of women who are vulnerable to the fatal consequences of unsafe abortion, especially in cases of rape, sexual assault, incest and where continuing a pregnancy would endanger the lives of women.