Human resource challenges in health systems: evidence from ten African countries.

Sub-Saharan Africa has fewer medical workers per capita than any region of the world, and that shortage has been highlighted consistently as a critical constraint to improving health outcomes in the region. This paper draws on newly available, systematic, comparable data from ten countries in the region to explore the dimensions of this shortage. We find wide variation in human resources performance metrics, both within and across countries. Many facilities are barely staffed, and effective staffing levels fall further when adjusted for health worker absences. However, caseloads-while also varying widely within and across countries-are also low in many settings, suggesting that even within countries, deployment rather than shortages, together with barriers to demand, may be the principal challenges. Beyond raw numbers, we observe significant proportions of health workers with very low levels of clinical knowledge on standard maternal and child health conditions. This work demonstrates that countries may need to invest broadly in health workforce deployment, improvements in capacity and performance of the health workforce, and on addressing demand constraints, rather than focusing narrowly on increases in staffing numbers.

Exploring patient safety risk in an emergency ward for substance use through a mixed-method analysis.

BACKGROUND: There is limited knowledge of how psychiatric patient safety measures can detect and understand risk as an emergent property within a healthcare system. Overcrowding poses a risk for patient safety in psychiatric emergency wards and is associated with increased mortality and violence. This paper aims to explore patterns of risk emergence in a psychiatric ward and provide insights into the dynamics of workload pressure. METHOD: A case study was conducted in a psychiatric emergency ward for patients with substance use disorders. The study employed a four-phased mixed-methods design. Phase one used clinical experts to identify patient safety pressure issues. Phase two used data on patient visits extracted from medical records between 2010 and 2020. In phase three, a quantitative analysis of patient visits and diagnosis was made. Phase four used a focus group of clinical experts for a semi-structured interview, analysing the result from phase three. RESULT: Trend analysis demonstrated a steady growth of patient visits to the emergency ward over the studied ten-year period. The findings showed a decrease in patients being diagnosed with delirium when visiting the emergency ward and an increase in percentage of patients receiving a psychosis diagnosis. The focus group expressed concerns about delayed treatments, increased violence and underestimating patients' needs. CONCLUSION: This study indicated that increased workload pressure can be predicted at a system level by analysing patient visits and diagnostics trends over time. The study advocates for ongoing awareness of patient safety risks by monitoring factors identified by clinical front-end workers as potential sources of risk. Healthcare management could employ supportive tools to detect and address emerging risks, including expected workload, overcrowding, staffing issues or bed shortages.

The Promise of Double Living. Understanding Young People with Same-Sex Desires in Contemporary Kampala.

Ugandan urban same-sex desiring individuals frequently encounter and navigate competing understandings of sexuality and sexual identity. Western essentialist understanding of sexual identity introduced by international development partners and transnational LGBT+ (Lesbian, Gay, Bi- and Transsexual) activism, as well as media, offer an alternative to Ugandan non-essentialist and fluid subject positions. This article seeks to understand how young individuals with same-sex -desires in Kampala navigate tensions between Western and local understandings concerning sexuality. We have interviewed 24 young individuals with same-sex desires (unaffiliated and individuals working in LGBT+ organizations) and asked how they approach their sexuality and experiences living with same-sex desires in contemporary Kampala. The results reveal how interview participants engaged in a complex navigation between local community expectations, their own same-sex desires, and embeddedness in a global LGBT+ culture. Although the participants engaged in what Westerners would label as a "double life," the article problematizes the prescriptive norms of authenticity and "coming out." The conclusion is that the fluid vs essentialist dichotomy is too simplistic to be helpful when trying to understand the lives and aspirations of young people with same-sex desires.

Artificial intelligence is an oxymoron: The importance of an organic body when facing unknown situations as they unfold in the present moment.

Departing from popular imaginations around artificial intelligence (AI), this article engages in the I in the AI acronym but from perspectives outside of mathematics, computer science and machine learning. When intelligence is attended to here, it most often refers to narrow calculating tasks. This connotation to calculation provides AI an image of scientificity and objectivity, particularly attractive in societies with a pervasive desire for numbers. However, as is increasingly apparent today, when employed in more general areas of our messy socio-cultural realities, AI- powered automated systems often fail or have unintended consequences. This article will contribute to this critique of AI by attending to Nicholas of Cusa and his treatment of intelligence. According to him, intelligence is equally dependent on an ability to handle the unknown as it unfolds in the present moment. This suggests that intelligence is organic which ties Cusa to more contemporary discussions in tech philosophy, neurology, evolutionary biology, and cognitive sciences in which it is argued that intelligence is dependent on having-and acting through-an organic body. Understanding intelligence as organic thus suggests an oxymoronic relationship to artificial.

Towards a Situated Understanding of Vulnerability - An Analysis of Ugandan LGBT+ Exposure to Hate Crimes in Digital Spaces.

This study maps Uganda LGBT+ experiences of online hate crime and analyzes how preexisting vulnerability morph in digital spaces. Based on field notes, workshop material, and interviews with 13 LGBT+ individuals, the study finds that digital presences in contexts where users are vulnerable due to state-sanctioned discrimination and social exclusion, digital arenas exacerbate users' vulnerability to hate crimes through their digital footprints. The longing for community and intimacy, together with in some cases an unfamiliarity with how digital media can be misused, appear to facilitate both the ideologically driven perpetrators hunting LGBT+, and Crime passionnel, where an (ex)partner miscalculates the implications of publishing private material. This study thus illustrates how digital spaces are not safe(r) spaces, where LGBT+ are free to playfully explore sexual orientation and gender non-conformity, away from society's abhorring gaze. Furthermore, contrary to what could be expected, LGBT+ individuals' vulnerability was most often not the result of an outside intruder hunting LGBT+ online. The article reiterates the importance of a situated approach, acknowledging the environmental influences when studying and addressing LGBT+ vulnerabilities in digital spaces.

Patterns of mortality risk among patients with substance use disorder: an opportunity for proactive patient safety?

BACKGROUND: Patients with substance use disorder (SUD) suffer from excess mortality compared to the overall population. This study aims to identify patterns in death rates among patients with SUD visiting a SUD emergency ward and to explore whether this knowledge can be used as input to identify patients at risk and increase patient safety. METHODS: Hospital visit data to a SUD emergency ward were collected between 2010 and 2020 through medical records. Data included gender, age, SUD diagnosis, and the time of death. The Kruskal-Wallis rank sum test was used to test between ordinal variables, and risk ratio was used to quantify the difference in mortality risk. All statistical tests were two-sided, with a 95% confidence interval and a minimum significance level of 0.05. RESULTS: The male patients in the study group had 1.41-1.59 higher mortality risk than the female patients. The study revealed an average death rate of 0.14 among all patients during the study period. Although patients with a diagnosed alcohol use disorder constituted 73.7% of the cohort, having an opioid use disorder or sedative hypnotics use disorder was associated with the highest death rates; 1.29-1.52 and 1.47-1.74 higher mortality risk than those without such diagnoses. CONCLUSION: This study demonstrates that data from visits to SUD emergency wards can be used to identify mortality risk factors, such as gender, type of diagnosis, number of diagnoses, and number of visits to the SUD emergency ward. Knowledge about patterns of patient visits and mortality risk could be used to increase patient safety through a decision support tool integrated with the electronic medical records. An improved system for early detection of increased mortality risk offers an opportunity for an adaptive patient safety system.

HIV, risk, and time preferences: Evidence from a general population sample in Lesotho.

Identifying individuals most at risk of HIV infection is a priority for policymakers. Apart from specific groups, however, little is known about how to identify those at high risk in the population. Research suggests that attitudes toward risk and time preferences may influence risky sexual behavior, but no studies have so far investigated the interplay between risk attitudes, time preference, and HIV infection. We collect data on risk and time preferences using hypothetical games (multiple price list method) at baseline and data on HIV status at baseline (2010) and endline (2012) allowing us to calculate incidence rate over a 2-year period among 675 participants, males and females 18-32 years old in Lesotho. We find robust evidence of a statistically significant positive associations between HIV incidence and prevalence and risk-loving attitudes, while the associations with risky behaviors and time preferences are not statistically significant. A measure of attitude toward risk, relatively easy to administer to individuals in a survey, is thus associated with future HIV status. This is an important finding for policymakers and suggests the importance of targeting HIV prevention programs to risk-loving individuals and therefore improving program efficiency.

Patient Safety Strategies in Psychiatry and How They Construct the Notion of Preventable Harm: A Scoping Review.

OBJECTIVES: The literature on patient safety in psychiatry has not been explored systematically in terms of what interventions are used, how they are used, and what type of (preventable) harm is targeted. The aims of this scoping review are to explore patient safety strategies used in psychiatry and determine how they construct the notion of preventable harm. METHOD: A scoping review of literature on patient safety in psychiatry published in English between 2000 and 2019 was conducted using Scopus, MEDLINE, PsycInfo, and CINAHL. Keywords of patient safety strategies and possible outcomes were coded from the results, discussion, or conclusion. Patient safety strategies were inductively categorized into themes according to the focus of the strategy. RESULTS: The review introduces 7 focus areas of patient safety strategies identified within the psychiatric literature: "risk management," "healthcare practitioners," "patient observation," "patient involvement," "computerized methods," "admission and discharge," and "security." The result shows that patient safety strategies mainly aim to reduce suicide, self-harm, violence, and falls and present a large diversity of measures, often aimed at reducing variability while increasing standardization. CONCLUSIONS: The strategies that are supported in the literature to achieve safer psychiatry mainly arise from linear cause-effect models and rely on staff performance, competence, and compliance. Contemporary safety science acknowledges the performance variability of everyday normal work and sees risk as the dynamic migration of these daily activities. The field of psychiatry has not yet included this view of safety in the strategic actions to reduce preventable harm.

Analysis of clinical knowledge, absenteeism and availability of resources for maternal and child health: a cross-sectional quality of care study in 10 African countries.

OBJECTIVE: Assess the quality of healthcare across African countries based on health providers' clinical knowledge, their clinic attendance and drug availability, with a focus on seven conditions accounting for a large share of child and maternal mortality in sub-Saharan Africa: malaria, tuberculosis, diarrhoea, pneumonia, diabetes, neonatal asphyxia and postpartum haemorrhage. METHODS: With nationally representative, cross-sectional data from ten countries in sub-Saharan Africa, collected using clinical vignettes (to assess provider knowledge), unannounced visits (to assess provider absenteeism) and visual inspections of facilities (to assess availability of drugs and equipment), we assess whether health providers are available and have sufficient knowledge and means to diagnose and treat patients suffering from common conditions amenable to primary healthcare. We draw on data from 8061 primary and secondary care facilities in Kenya, Madagascar, Mozambique, Nigeria, Niger, Senegal, Sierra Leone, Tanzania, Togo and Uganda, and 22 746 health workers including doctors, clinical officers, nurses and community health workers. Facilities were selected using a multistage cluster-sampling design to ensure data were representative of rural and urban areas, private and public facilities, and of different facility types. These data were gathered under the Service Delivery Indicators programme. RESULTS: Across all conditions and countries, healthcare providers were able to correctly diagnose 64% (95% CI 62% to 65%) of the clinical vignette cases, and in 45% (95% CI 43% to 46%) of the cases, the treatment plan was aligned with the correct diagnosis. For diarrhoea and pneumonia, two common causes of under-5 deaths, 27% (95% CI 25% to 29%) of the providers correctly diagnosed and prescribed the appropriate treatment for both conditions. On average, 70% of health workers were present in the facilities to provide care during facility hours when those workers are scheduled to be on duty. Taken together, we estimate that the likelihood that a facility has at least one staff present with competency and key inputs required to provide child, neonatal and maternity care that meets minimum quality standards is 14%. On average, poor clinical knowledge is a greater constraint in care readiness than drug availability or health workers' absenteeism in the 10 countries. However, we document substantial heterogeneity across countries in the extent to which drug availability and absenteeism matter quantitatively. CONCLUSION: Our findings highlight the need to boost the knowledge of healthcare workers to achieve greater care readiness. Training programmes have shown mixed results, so systems may need to adopt a combination of competency-based preservice and in-service training for healthcare providers (with evaluation to ensure the effectiveness of the training), and hiring practices that ensure the most prepared workers enter the systems. We conclude that in settings where clinical knowledge is poor, improving drug availability or reducing health workers' absenteeism would only modestly increase the average care readiness that meets minimum quality standards.

Visualizing healthcare system variability and resilience: a longitudinal study of patient movements following discharge from a Swedish psychiatric clinic.

BACKGROUND: As healthcare becomes increasingly complex, new methods are needed to identify weaknesses in the system that could lead to increased risk. Traditionally, the focus for patient safety is to study incident reports and adverse events, but that starting point has been contested with a new era of safety investigations: the analysis of everyday clinical work, and the resilient healthcare. This study introduces a new approach of system monitoring as a way to strengthen patient safety and has focused on discharge in psychiatry as a risk for adverse outcomes. The aim was to analyse a psychiatric clinic's everyday 'normal' performance variability of discharge from inpatient psychiatric care to outpatient care. METHOD: A retrospective longitudinal correlation study with a strategic selection. Data consist of 70,797 patient visits within one psychiatric clinic, and the visits were compared between 81 different wards in Stockholm County by using a model of time-lapse visualization. RESULTS: The time-lapse visualization shows a discrepancy in types of visits and the proportion of cancelled visits to the outward units. 42% of all patients that were scheduled as an outward patient, did not complete this transition, but instead, they revisit the clinics' emergency ward and did not receive the planned care treatment. The patients who visit the emergency ward instead of their planned outpatient visit did this within 20 days. CONCLUSIONS: The findings show a potential increased demand for emergency psychiatric care from 2010 to 2018 within the clinic. It also suggests that the healthcare system creates a space of temporal as well as functional variability, and that patients use this space to adapt to their changing conditions. This understanding can assist management in prioritising allocation of resources and thereby strengthen patient safety. Today's incident reporting systems in healthcare are ineffective in monitoring patterns of more cancelled visits in outward units and sooner visit to the emergency ward. By using time-lapse visualization of patient interactions, stakeholders might analyse current-, and estimate future, stressors within the system to identify and understand potential system migration towards risk in healthcare. This could help healthcare management understand where resources should be prioritized.

Bayesian modeling of microwave radiometer calibration on the example of the Wendelstein 7-X electron cyclotron emission diagnostic.

This paper reports about a novel approach to the absolute intensity calibration of an electron cyclotron emission (ECE) spectroscopy system. Typically, an ECE radiometer consists of tens of separated frequency channels corresponding to different plasma locations. An absolute calibration of the overall diagnostic including near plasma optics and transmission line is achieved with blackbody sources at LN2 temperature and room temperature via a hot/cold calibration mirror unit. As the thermal emission of the calibration source is typically a few thousand times lower than the receiver noise temperature, coherent averaging over several hours is required to get a sufficient signal to noise ratio. A forward model suitable for any radiometer calibration using the hot/cold method and a periodic switch between them has been developed and used to extract the voltage difference between the hot and cold temperature source via Bayesian analysis. In contrast to the classical analysis which evaluates only the reference temperatures, the forward model takes into account intermediate effective temperatures caused by the finite beam width and thus uses all available data optimally. This allows the evaluation of weak channels where a classical analysis would not be feasible, is statistically rigorous, and provides a measurement of the beam width. By using a variance scaling factor, a model sensitive adaptation of the absolute uncertainties can be implemented, which will be used for the combined diagnostic Bayesian modeling analysis.