Fetal alcohol spectrum disorder resources for health professionals: a scoping review.

OBJECTIVES: This scoping review aimed to identify and critically appraise resources for health professionals to identify, diagnose, refer, and support individuals with fetal alcohol spectrum disorder (FASD)-including the extent to which the resources are appropriate for use in communities with First Nations Peoples. METHOD: Seven peer-reviewed databases (April 2022) and 14 grey literature websites (August 2022) were searched. The reference lists of all sources that underwent full-text review were handsearched, and FASD experts were consulted for additional sources. Resources were assessed using the Appraisal of Guidelines for REsearch and Evaluation II instrument and an adapted version of the National Health and Medical Research Council FORM Framework and iCAHE Guideline Quality Checklist. RESULTS: A total of 41 resources underwent data extraction and critical appraisal, as screening and/or diagnosis guidelines were excluded because they are covered in other reviews. Most were recently published or updated (n=24), developed in the USA (n=15, 36.6%) or Australia (n=12, 29.3%) and assisted with FASD patient referral or support (n=40). Most management guidelines scored 76%-100% on overall quality assessment (n=5/9) and were recommended for use in the Australian context with modifications (n=7/9). Most of the guides (n=15/22) and factsheets (n=7/10) received a 'good' overall score. Few (n=3/41) resources were explicitly designed for or with input from First Nations Australians. CONCLUSION: High-quality resources are available to support health professionals providing referrals and support to individuals with FASD, including language guides. Resources should be codesigned with people living with FASD to capture and integrate their knowledge and preferences.

Health services for aboriginal and Torres Strait Islander children in remote Australia: A scoping review.

In Australia, there is a significant gap between health outcomes in Indigenous and non-Indigenous children, which may relate to inequity in health service provision, particularly in remote areas. The aim was to conduct a scoping review to identify publications in the academic and grey literature and describe 1) Existing health services for Indigenous children in remote Australia and service use, 2) Workforce challenges in remote settings, 3) Characteristics of an effective health service, and 4) Models of care and solutions. Electronic databases of medical/health literature were searched (Jan 1990 to May 2021). Grey literature was identified through investigation of websites, including of local, state and national health departments. Identified papers (n = 1775) were screened and duplicates removed. Information was extracted and summarised from 116 papers that met review inclusion criteria (70 from electronic medical databases and 45 from the grey literature). This review identified that existing services struggle to meet demand. Barriers to effective child health service delivery in remote Australia include availability of trained staff, limited services, and difficult access. Aboriginal and Community Controlled Health Organisations are effective and should receive increased support including increased training and remuneration for Aboriginal Health Workers. Continuous quality assessment of existing and future programs will improve quality; as will measures that reflect aboriginal ways of knowing and being, that go beyond traditional Key Performance Indicators. Best practice models for service delivery have community leadership and collaboration. Increased resources with a focus on primary prevention and health promotion are essential.

The Global Impact of COVID-19 on Childhood Cancer Outcomes and Care Delivery - A Systematic Review.

Background: Childhood cancer represents a leading cause of death and disease burden in high income countries (HICs) and low-and-middle income countries (LMICs). It is postulated that the current COVID-19 pandemic has hampered global development of pediatric oncology care programs. This systematic review aimed to comprehensively review the global impact of COVID-19 on childhood cancer clinical outcomes and care delivery. Methods: A systematic search was conducted on PubMed, Embase, Medline, and the African Medical Index from inception to November 3, 2021 following PRISMA guidelines. A manual search was performed to identify additional relevant studies. Articles were selected based on predetermined eligibility criteria. Findings: The majority of studies reported patients with cancer and COVID-19 presenting as asymptomatic (HICs: 33.7%, LMICs: 22.0%) or with primary manifestations of fever (HICs: 36.1%, LMICs: 51.4%) and respiratory symptoms (HICs: 29.6%, LMICs: 11.7%). LMICs also reported a high frequency of patients presenting with cough (23.6%) and gastrointestinal symptoms (10.6%). The majority of patients were generally noted to have a good prognosis; however the crude mortality rate was higher in LMICs when compared to HICs (8.0% vs 1.8%). Moreover, the pandemic has resulted in delays and interruptions to cancer therapies and delays in childhood cancer diagnoses in both HICs and LMICs. However, these findings were disproportionately reported in LMICs, with significant staff shortages, supply chain disruptions, and limited access to cancer therapies for patients. Conclusions: The COVID-19 pandemic has resulted in delays and interruptions to childhood cancer therapies and delays in childhood cancer diagnoses, and disproportionately so within LMICs. This review provides lessons learned for future system-wide disruptions to care, as well as provides key points for moving forward better with care through the remainder of this pandemic. Systematic Review Registration: CRD42021266758, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=266758.

Emergency Department Presentations by Children in Remote Australia: A Population-based Study.

Background. Aboriginal leaders invited us to examine the frequency and reasons for emergency department (ED) presentations by children in remote Western Australia, where Prenatal Alcohol Exposure (PAE) is common. Methods. ED presentations (2007-11 inclusive) were examined for all children born in the Fitzroy Valley in 2002-03. Results. ED data for 127/134 (94.7%) children (95% Aboriginal) showed 1058 presentations over 5-years. Most (81%) had at least 1 presentation (median 9.0, range 1-50). Common presentations included: screening/follow-up/social reasons (16.0%), injury (15.1%), diseases of the ear (14.9%), skin (13.8%), respiratory tract (13.4%), and infectious and parasitic diseases (9.8%). PAE and higher presentations rates were associated. Commonly associated socio-economic factors were household over-crowding, financial and food insecurity. Conclusion. Children in very remote Fitzroy Crossing communities have high rates of preventable ED presentations, especially those with PAE. Support for culturally appropriate preventative programs and improved access to primary health services need to be provided in remote Australia.

Research protocol for the Picture Talk Project: a qualitative study on research and consent with remote Australian Aboriginal communities.

INTRODUCTION: Research with Indigenous populations is not always designed with cultural sensitivity. Few publications evaluate or describe in detail seeking consent for research with Indigenous participants. When potential participants are not engaged in a culturally respectful manner, participation rates and research quality can be adversely affected. It is unethical to proceed with research without truly informed consent. METHODS AND ANALYSIS: We describe a culturally appropriate research protocol that is invited by Aboriginal communities of the Fitzroy Valley in Western Australia. The Picture Talk Project is a research partnership with local Aboriginal leaders who are also chief investigators. We will interview Aboriginal leaders about research, community engagement and the consent process and hold focus groups with Aboriginal community members about individual consent. Cultural protocols will be applied to recruit and conduct research with participants. Transcripts will be analysed using NVivo10 qualitative software and themes synthesised to highlight the key issues raised by the community about the research process. This protocol will guide future research with the Aboriginal communities of the Fitzroy Valley and may inform the approach to research with other Indigenous communities of Australia or the world. It must be noted that no community is the same and all research requires local consultation and input. To conduct culturally sensitive research, respected local people from the community who have knowledge of cultural protocol and language are engaged to guide each step of the research process from the project design to the delivery of results. ETHICS AND DISSEMINATION: Ethics approval was granted by the University of Sydney Human Research Ethics Committee (No. 2012/348, reference:14760), the Western Australia Country Health Service Ethics Committee (No. 2012:15), the Western Australian Aboriginal Health Ethics Committee and reviewed by the Kimberley Aboriginal Health Planning Forum Research Sub-Committee (No. 2012-008). Results will be disseminated through peer review articles, a local Fitzroy Valley report and conference presentations.

Pediatric hospital admissions in Indigenous children: a population-based study in remote Australia.

BACKGROUND: We analysed hospital admissions of a predominantly Aboriginal cohort of children in the remote Fitzroy Valley in Western Australia during the first 7 years of life. METHODS: All children born between January 1, 2002 and December 31, 2003 and living in the Fitzroy Valley in 2009-2010 were eligible to participate in the Lililwan Project. Of 134 eligible children, 127 (95%) completed Stage 1 (interviews of caregivers and medical record review) in 2011 and comprised our cohort. Lifetime (0-7 years) hospital admission data were available and included the dates, and reasons for admission, and comorbidities. Conditions were coded using ICD-10-AM discharge codes. RESULTS: Of the 127 children, 95.3% were Indigenous and 52.8% male. There were 314 admissions for 424 conditions in 89 (70.0%) of 127 children. The 89 children admitted had a median of five admissions (range 1-12). Hospitalization rates were similar for both genders (p = 0.4). Of the admissions, 108 (38.6%) were for 56 infants aged <12 months (median = 2.5, range = 1-8). Twelve of these admissions were in neonates (aged 0-28 days). Primary reasons for admission (0-7 years) were infections of the lower respiratory tract (27.4%), gastrointestinal system (22.7%), and upper respiratory tract (11.4%), injury (7.0%), and failure to thrive (5.4%). Comorbidities, particularly upper respiratory tract infections (18.1%), failure to thrive (13.6%), and anaemia (12.7%), were common. In infancy, primary cause for admission were infections of the lower respiratory tract (40.8%), gastrointestinal (25.9%) and upper respiratory tract (9.3%). Comorbidities included upper respiratory tract infections (33.3%), failure to thrive (18.5%) and anaemia (18.5%). CONCLUSION: In the Fitzroy Valley 70.0% of children were hospitalised at least once before age 7 years and over one third of admissions were in infants. Infections were the most common reason for admission in all age groups but comorbidities were common and may contribute to need for admission. Many hospitalizations were feasibly preventable. High admission rates reflect disadvantage, remote location and limited access to primary healthcare and outpatient services. Ongoing public health prevention initiatives including breast feeding, vaccination, healthy diet, hygiene and housing improvements are crucial, as is training of Aboriginal Health Workers to increase services in remote communities.

Institutional analysis of health system governance.

It is important that researchers who study health system governance have a set of collective understandings of the meanings of governance, which can then inform the methods used in research. We present an institutional framing and definition of health system governance; that is, governance refers to making, changing, monitoring and enforcing the rules that govern the demand and supply of health services. This pervasive, relational view of governance is to be preferred to approaches that focus primarily on structures of governments and health care organizations, because health system governance involves communities and service users, and because governments in many low- and middle-income countries tend to under-govern. Therefore, the study of health system governance requires institutional analysis; an approach that focuses not only on structures, but also on the rules (both formal and informal) governing demand and supply relations. Using this 'structure-relations' lens, and based on our field experience, we discuss how this focus could be applied to the three approaches to framing and studying health system governance that we identified in the literature. In order of decreasing focus on structures ('hardware') and increasing focus on relations ('software'), they are: (1) the government-centred approach, which focuses on the role of governments, above or to the exclusion of non-government health system actors; (2) the building-block approach, which focuses on the internal workings of health care organizations, and treats governance as one of the several building blocks of organizations; and (3) the institutional approach, which focuses on how the rules governing social and economic interactions are made, changed, monitored and enforced. Notably, either or both qualitative and quantitative methods may be used by researchers in efforts to incorporate the analysis of how rules determine relations among health system actors into these three approaches to health system governance.

Plagiocephaly and Developmental Delay: A Systematic Review.

OBJECTIVE: Deformational plagiocephaly (includes plagiocephaly and brachycephaly) is a common pediatric condition. Infants who present with altered head shape often experience developmental delay. It is uncertain how common developmental delay is in infants with plagiocephaly and how sustained this is, when present. This review explores the association between plagiocephaly and developmental delay to guide clinical practice. STUDY DESIGN: A systematic review was conducted. MEDLINE, EMBASE, CINAHL, and PEDro databases were searched. Data from relevant studies were extracted regarding study: sample, follow-up, design, and findings. Methodological quality of each study was rated using a critical appraisal tool. RESULTS: The search recovered 1315 articles of which 19 met the inclusion criteria. In the included studies, the children's ages ranged from 3 months to 10 years. Study limitations included selection bias, nonblinding of assessors, and reuse of the same study population for multiple papers. Most papers (11/19) rated "moderate" on methodological quality. A positive association between plagiocephaly and developmental delay was reported in 13 of 19 studies, including 4 of 5 studies with "strong" methodological quality. Delay was more frequently in studies with children ≤24 months of age (9/12 studies) compared with >24 months of age (3/7 studies). Motor delay was the most commonly affected domain reported in high-quality papers (5/5 studies). CONCLUSION: This review suggests plagiocephaly is a marker of elevated risk of developmental delays. Clinicians should closely monitor infants with plagiocephaly for this. Prompt referral to early intervention services such as physiotherapy may ameliorate motor delays and identify infants with longer term developmental needs.

Assessing the experience of social support for parents who attended Camp Trillium's pediatric oncology family program.

When a child is diagnosed with cancer, the entire family is affected by the demands of the illness and its treatment. This study aimed to provide a more nuanced understanding of the experience of parents of children with cancer when participating in therapeutic recreation programs (such as summer camp) and to address the specific knowledge gap of the role that camp may play in providing social support for these families. In particular, this study aimed to enroll mothers and fathers, as the voice of fathers has previously been missing in research about cancer camps. METHOD: Qualitative methods were used to better understand the experiences of parents (n = 85) attending Camp Trillium's family program between June 26th and August 31st of 2012. Data obtained were analyzed using a grounded theory approach and thus coded and then grouped using thematic analysis. Parents reported that they experienced valuable peer interaction and experienced an increase in their perceived social support. They also stated that this support was sustained outside of the camp experience. Parents highlighted the important aspects of camp as: the empowering setting, time to escape the treatment routine, and rebuild familial relationships. From the qualitative interviews, five distinct themes were explicated: (a) empowering setting, (b) restoring family relationships, (c) valuable peer interactions, (d) information sharing, and (e) group tensions. In addition to respite and recreational opportunities, camp provides access to an environment and community that has the ability to provide sustained and empowering support for parents dealing with childhood cancer, notably for fathers.

Where there is no policy: governing the posting and transfer of primary health care workers in Nigeria.

The posting and transfer of health workers and managers receives little policy and research attention in global health. In Nigeria, there is no national policy on posting and transfer in the health sector. We sought to examine how the posting and transfer of frontline primary health care (PHC) workers is conducted in four states (Lagos, Benue, Nasarawa and Kaduna) across Nigeria, where public sector PHC facilities are usually the only form of formal health care service providers available in many communities. We conducted in-depth interviews with PHC workers and managers, and group discussions with community health committee members. The results revealed three mechanisms by which PHC managers conduct posting and transfer: (1) periodically moving PHC workers around as a routine exercise aimed at enhancing their professional experience and preventing them from being corrupted; (2) as a tool for improving health service delivery by assigning high-performing PHC workers to PHC facilities perceived to be in need, or posting PHC workers nearer their place of residence; and (3) as a response to requests for punishment or favour from PHC workers, political office holders, global health agencies and community health committees. Given that posting and transfer is conducted by discretion, with multiple influences and sometimes competing interests, we identified practices that may lead to unfair treatment and inequities in the distribution of PHC workers. The posting and transfer of PHC workers therefore requires policy measures to codify what is right about existing informal practices and to avert their negative potential. © 2016 The Authors The International Journal of Health Planning and Management Published by John Wiley & Sons Ltd.

Information, regulation and coordination: realist analysis of the efforts of community health committees to limit informal health care providers in Nigeria.

One of the consequences of ineffective governments is that they leave space for unlicensed and unregulated informal providers without formal training to deliver a large proportion of health services. Without institutions that facilitate appropriate health care transactions, patients tend to navigate health care markets from one inappropriate provider to another, receiving sub-optimal care, before they find appropriate providers; all the while incurring personal transaction costs. But the top-down interventions to address this barrier to accessing care are hampered by weak governments, as informal providers are entrenched in communities. To explore the role that communities could play in limiting informal providers, we applied the transaction costs theory of the firm which predicts that economic agents tend to organise production within firms when the costs of coordinating exchange through the market are greater than within a firm. In a realist analysis of qualitative data from Nigeria, we found that community health committees sometimes seek to limit informal providers in a manner that is consistent with the transaction costs theory of the firm. The committees deal not through legal sanction but by subtle influence and persuasion in a slow and faltering process of institutional change, leveraging the authority and resources available within their community, and from governments and NGOs. First, they provide information to reduce the market share controlled by informal providers, and then regulation to keep informal providers at bay while making the formal provider more competitive. When these efforts are ineffective or insufficient, committees are faced with a "make-or-buy" decision. The "make" decision involves coordination to co-produce formal health services and facilitate referrals from informal to formal providers. What sometimes results is a quasi-firm-informal and formal providers are networked in a single but loose production unit. These findings suggest that efforts to limit informal providers should seek to, among other things, augment existing community responses.

Seeking consent for research with indigenous communities: a systematic review.

BACKGROUND: When conducting research with Indigenous populations consent should be sought from both individual participants and the local community. We aimed to search and summarise the literature about methods for seeking consent for research with Indigenous populations. METHODS: A systematic literature search was conducted for articles that describe or evaluate the process of seeking informed consent for research with Indigenous participants. Guidelines for ethical research and for seeking consent with Indigenous people are also included in our review. RESULTS: Of 1447 articles found 1391 were excluded (duplicates, irrelevant, not in English); 56 were relevant and included. Articles were categorised into original research that evaluated the consent process (n = 5) or publications detailing the process of seeking consent (n = 13) and guidelines for ethical research (n = 38). Guidelines were categorised into international (n = 8); national (n = 20) and state/regional/local guidelines (n = 10). In five studies based in Australia, Canada and The United States of America the consent process with Indigenous people was objectively evaluated. In 13 other studies interpreters, voice recording, videos, pictures, flipcharts and "plain language" forms were used to assist in seeking consent but these processes were not evaluated. Some Indigenous organisations provide examples of community-designed resources for seeking consent and describe methods of community engagement, but none are evaluated. International, national and local ethical guidelines stress the importance of upholding Indigenous values but fail to specify methods for engaging communities or obtaining individual consent. In the 'Grey literature' concerns about the consent process are identified but no solutions are offered. CONCLUSION: Consultation with Indigenous communities is needed to determine how consent should be sought from the community and the individual, and how to evaluate this process.

The impact of a knowledge translation intervention employing educational outreach and a point-of-care reminder tool vs standard lay health worker training on tuberculosis treatment completion rates: study protocol for a cluster randomized controlled trial.

BACKGROUND: Despite availability of effective treatment, tuberculosis (TB) remains an important cause of morbidity and mortality globally, with low- and middle-income countries most affected. In many such settings, including Malawi, the high burden of disease and severe shortage of skilled healthcare workers has led to task-shifting of outpatient TB care to lay health workers (LHWs). LHWs improve access to healthcare and some outcomes, including TB completion rates, but lack of training and supervision limit their impact. The goals of this study are to improve TB care provided by LHWs in Malawi by refining, implementing, and evaluating a knowledge translation strategy designed to address a recognized gap in LHWs' TB and job-specific knowledge and, through this, to improve patient outcomes. METHODS/DESIGN: We are employing a mixed-methods design that includes a pragmatic cluster randomized controlled trial and a process evaluation using qualitative methods. Trial participants will include all health centers providing TB care in four districts in the South East Zone of Malawi. The intervention employs educational outreach, a point-of-care reminder tool, and a peer support network. The primary outcome is proportion of treatment successes, defined as the total of TB patients cured or completing treatment, with outcomes taken from Ministry of Health treatment records. With an alpha of 0.05, power of 0.80, a baseline treatment success of 0.80, intraclass correlation coefficient of 0.1 based on our pilot study, and an estimated 100 clusters (health centers providing TB care), a minimum of 6 patients per cluster is required to detect a clinically significant 0.10 increase in the proportion of treatment successes. Our process evaluation will include interviews with LHWs and patients, and a document analysis of LHW training logs, quarterly peer trainer meetings, and mentorship meeting notes. An estimated 10-15 LHWs and 10-15 patients will be required to reach saturation in each of 2 planned interview periods, for a total of 40-60 interview participants. DISCUSSION: This study will directly inform the efforts of knowledge users within TB care and, through extension of the approach, other areas of care provided by LHWs in Malawi and other low- and middle-income countries. TRIAL REGISTRATION: ClinicalTrials.gov NCT02533089 . Registered 20 August 2015. Protocol Date/Version 29 May 2016/Version 2.

Lay Health Workers experience of a tailored knowledge translation intervention to improve job skills and knowledge: a qualitative study in Zomba district Malawi.

BACKGROUND: Like many sub-Saharan African countries, Malawi is facing a critical shortage of skilled healthcare workers. In response to this crisis, a formal cadre of lay health workers (LHW) has been established and now carries out several basic health care services, including outpatient TB care and adherence support. While ongoing training and supervision are recognized as essential to the effectiveness of LHW programs, information is lacking as to how these needs are best addressed. The objective of this qualitative study was to explore LHWs responses to a tailored knowledge translation intervention they received, designed to address a previously identified training and knowledge gap. METHODS: Forty-five interviews were conducted with 36 healthcare workers. Fourteen to sixteen interviews were done at each of 3 evenly spaced time blocks over a one year period, with 6 individuals interviewed more than once to assess for change both within and across individuals overtime. RESULTS: Reported benefits of the intervention included: increased TB, HIV, and job-specific knowledge; improved clinical skills; and increased confidence and satisfaction with their work. Suggestions for improvement were less consistent across participants, but included: increasing the duration of the training, changing to an off-site venue, providing stipends or refreshments as incentives, and adding HIV and drug dosing content. CONCLUSIONS: Despite the significant departure of the study intervention from the traditional approach to training employed in Malawi, the intervention was well received and highly valued by LHW participants. Given the relative low-cost and flexibility of the methods employed, this appears a promising approach to addressing the training needs of LHW programs, particularly in Low- and Middle-income countries where resources are most constrained.

'The government cannot do it all alone': realist analysis of the minutes of community health committee meetings in Nigeria.

Since the mid-1980s, the national health policy in Nigeria has sought to inspire community engagement in primary health care by bringing communities into partnership with service providers through community health committees. Using a realist approach to understand how and under what circumstances the committees function, we explored 581 meeting minutes from 129 committees across four states in Nigeria (Lagos, Benue, Nasarawa and Kaduna). We found that community health committees provide opportunities for improving the demand and supply of health care in their community. Committees demonstrate five modes of functioning: through meetings (as 'village square'), reaching out within their community (as 'community connectors'), lobbying governments for support (as 'government botherers'), inducing and augmenting government support (as 'back-up government') and taking control of health care in their community (as 'general overseers'). In performing these functions, community health committees operate within and through the existing social, cultural and religious structures of their community, thereby providing an opportunity for the health facility with which they are linked to be responsive to the needs and values of the community. But due to power asymmetries, committees have limited capacity to influence health facilities for improved performance, and governments for improved health service provision. This is perhaps because national guidelines are not clear on their accountability functions; they are not aware of the minimum standards of services to expect; and they have a limited sense of legitimacy in their relations with sub-national governments because they are established as the consequence of a national policy. Committees therefore tend to promote collective action for self-support more than collective action for demanding accountability. To function optimally, community health committees require national government or non-government organization mentoring and support; they need to be enshrined in law to bolster their sense of legitimacy; and they also require financial support to subsidise their operation costs especially in geographically large communities.

High alcohol use a strong and significant risk factor for repetitive self-harm in female and male youth: a prospective cohort study.

BACKGROUND: Deliberate self-harm (DSH) is reported by between 5 and 17% of youth aged 14-25 years. Current management measures focus on repetition prevention in high-risk groups. OBJECTIVES: To examine risk factors and predictors of DSH and DSH repetition in a community sample, by gender. METHODS: A prospective cohort of 20,822 young adults (aged 17-24 years) was recruited when obtaining their driving license. A random sample of 5000 was approached for follow-up 12-18 months; 2991 (60%) responded and formed the cohort for this analysis. Patterns of self-harm, using a modified Beck Suicide Inventory, were investigated with logistic regression. RESULTS: DSH was reported by 4.1% (123/2991) at baseline. Over the following 12 months, 3.0% (90/2991) reported new instances of DSH which included 20% (25) respondents who had engaged in DSH at baseline. Psychological distress was a risk factor for engaging in DSH in the past 12 months, OR 3.55 (95% CI 2.06-6.14). Although several clinical risk factors differed between genders, high alcohol use, OR 23.6 (95% CI 3.64-153) and psychological distress, OR 4.97 (95% CI 1.08-22.9) were significant risk factors for repeat DSH in both males and females. CONCLUSION: In this community cohort, 1 in 25 youth had self-harmed in the year prior; of these, 4 in 5 did not repeat DSH over the following year. High alcohol use stands out as a strong risk factor for DSH repetition. Assessing alcohol use may help clinicians identify those who are at greatest risk for repetitive self-harm.

Evaluation as evolution: a Darwinian proposal for health policy and systems research.

BACKGROUND: Health systems are complex and health policies are political. While grand policies are set by politicians, the detailed implementation strategies which influence the shape and impact of these policies are delegated to technical personnel. This is an underappreciated opportunity for optimising health systems. We propose that selective 'breeding' through successive evaluations of and selection among implementation strategies is a metaphor that health system thinkers can use to improve health care. DISCUSSION: Similar to Darwinian evolution, the acceptance and accumulation of successful choices and the detection and discarding of unsuccessful ones would improve health systems in small and uncontroversial ways, over time. The effects of better implementation choices would be synergistic and cumulative, accumulating large impact (and lessons) from small changes. Just as with evolution of species, this means that even slight improvements over usual outcomes makes these numerous small choices as important a focus for system improvement as the overarching policy itself. Several alternative implementation approaches can be compared under real-world conditions in prospective head-to-head experimental and non-experimental explorations to understand whether and to what extent a strategy works and what works for whom, how, and under what circumstances in different locations. As in breeding or evolution, the best variants would spread to become the new, proven superior, implementation strategies for that policy in those settings. CONCLUSIONS: Evolution does not produce a new species whole, in a single transaction. Instead it gathers new parts and powers over time as different combinations are tested through competition with one another, to survive and spread or become extinct. Without necessarily changing or challenging grand policies, extending this idea to health systems innovation can facilitate thinking around how local, small - but cumulative - improvements in implementation potentially contribute to a pattern of successive adaptation spreading within its viable niche and ultimately providing locally-derived, long-term improvements in health systems.

A knowledge translation intervention to improve tuberculosis care and outcomes in Malawi: a pragmatic cluster randomized controlled trial.

BACKGROUND: Lay health workers (LHWs) play a pivotal role in addressing the high TB burden in Malawi. LHWs report lack of training to be a key barrier to their role as TB care providers. Given the cost of traditional off-site training, an alternative approach is needed. Our objective was to evaluate the effectiveness of a KT intervention tailored to LHWs needs. METHODS: The study design is a pragmatic cluster randomized trial. The study was embedded within a larger trial, PALMPLUS, and compared three arms which included 28 health centers in Zomba district, Malawi. The control arm included 14 health centers randomized as controls in the larger trial and maintained as control sites. Seven of 14 PALMPLUS intervention sites were randomized to the LHW intervention (PALM/LHW intervention arm), and the remaining 7 PALMPLUS sites maintained as a PALM only arm. PALMPLUS intervention sites received an educational outreach program targeting mid-level health workers. LHW intervention sites received both the PALMPLUS intervention and the LHW intervention employing on-site peer-led educational outreach and a point-of-care tool tailored to LHWs identified needs. Control sites received no intervention. The main outcome measure is the proportion of treatment successes. RESULTS: Among the 28 sites, there were 178 incident TB cases with 46/80 (0.58) successes in the control group, 44/68 (0.65) successes in the PALMPLUS group, and 21/30 (0.70) successes in the PALM/LHW intervention group. There was no significant effect of the intervention on treatment success in the univariate analysis adjusted for cluster randomization (p = 0.578) or multivariate analysis controlling for covariates with significant model effects (p = 0.760). The overall test of the intervention-arm by TB-type interaction approached but did not achieve significance (p = 0.056), with the interaction significant only in the control arm [RR of treatment success for pulmonary TB relative to non-pulmonary TB, 1.18, 95% CI 1.05-1.31]. CONCLUSIONS: We found no significant treatment effect of our intervention. Given the identified trend for effectiveness and urgent need for low-cost approaches to LHW training, further evaluation of tailored KT strategies as a means of LHW training in Malawi and other LMICs is warranted. TRIAL REGISTRATION: ClinicalTrials.gov NCT01356095 .

Transaction costs of access to health care: Implications of the care-seeking pathways of tuberculosis patients for health system governance in Nigeria.

Health care costs incurred prior to the appropriate patient-provider transaction (i.e., transaction costs of access to health care) are potential barriers to accessing health care in low- and middle-income countries. This paper explores these transaction costs and their implications for health system governance through a cross-sectional survey of adult patients who received their first diagnosis of pulmonary tuberculosis (TB) at the three designated secondary health centres for TB care in Ebonyi State, Nigeria. The patients provided information on their care-seeking pathways and the associated costs prior to reaching the appropriate provider. Of the 452 patients, 84% first consulted an inappropriate provider. Only 33% of inappropriate consultations were with qualified providers (QP); the rest were with informal providers such as pharmacy providers (PPs; 57%) and traditional providers (TP; 10%). Notably, 62% of total transaction costs were incurred during the first visit to an inappropriate provider and the mean transaction costs incurred was highest with QPs (US$30.20) compared with PPs (US$14.40) and TPs (US$15.70). These suggest that interventions for reducing transaction costs should include effective decentralisation to integrate TB care with services at the primary health care level, community engagement to address information asymmetry, enforcing regulations to keep informal providers within legal limits and facilitating referral linkages among formal and informal providers to increase early contact with appropriate providers.

Prevalence and patterns of alcohol use in pregnancy in remote Western Australian communities: The Lililwan Project.

INTRODUCTION AND AIMS: Alcohol use in pregnancy is thought to be common in remote Australian communities, but no population-based data are available. Aboriginal leaders in remote Western Australia invited researchers to determine the prevalence and patterns of alcohol use in pregnancy within their communities. DESIGN AND METHODS: A population-based survey of caregivers of all children born in 2002/2003 and living in the Fitzroy Valley in 2010/2011 (n = 134). Alcohol use risk was categorised using the Alcohol Use Disorders Identification Test consumption subset (AUDIT-C) tool. Birth and child outcomes were determined by interview, medical record review and physical examination. RESULTS: 127/134 (95%) eligible caregivers participated: 78% were birth mothers, 95% were Aboriginal and 55% reported alcohol use in index pregnancies; 88% reported first trimester drinking and 53% drinking in all trimesters. AUDIT-C scores were calculated for 115/127 women, of whom 60 (52%) reported alcohol use in pregnancy. Of the 60 women who drank (AUDIT-C score ≥ 1), 12% drank daily/almost daily, 33% drank 2-3 times per week; 71% drank ≥ 10 standard drinks on a typical occasion; 95% drank at risky or high-risk levels (AUDIT-C score ≥ 4). Mean AUDIT-C score was 8.5 ± 2.3 (range 2-12). The most common drinking pattern was consumption of ≥ 10 standard drinks either 2-4 times per month (27%) or 2-3 times per week (27%). DISCUSSION AND CONCLUSIONS: High-risk alcohol use in pregnancy is common in remote, predominantly Aboriginal communities in north western Australia. Prevention strategies to reduce prenatal alcohol use are urgently needed.