Integrated reproductive health services: the perspectives of providers

With the advent of the AIDS epidemic the focus of family planning programmes has shifted from an emphasis on pregnancy prevention to include disease prevention. The move towards integration has meant a major re-orientation in the role of health providers. This article seeks to expand knowledge about the implementation of integrated services from the perspective of providers. It focuses more specifically on the provider's perceptions and experiences of integrated services. A range of methods is used to obtain information from providers, including an inventory of health facilities, in-depth interviews and focus group discussions. The results suggest that the majority of providers expressed favourable attitudes to integrated services. Integrated services are seen as a more client centred approach. However, there is a lack of clarity about the precise from that integration should take. As a result, providers seem more comfortable with the traditional focus on family planning and maternal and child health than sexually transmitted infections.     

Enroling and retaining human immunodeficiency virus (HIV) patients in their care: A metasynthesis of qualitative studies

ObjectivesTo report the findings of a metasynthesis review of qualitative studies on patient and provider experiences and perspectives on linkage and retention in HIV care.DesignThe review is an extraction, aggregation, interpretation and synthesis of qualitative findings based on the Sandelowski and Barroso method.Data sourcesA search of the literature was conducted in the databases Cumulative Index to Nursing and Allied Health, PubMed and PsycInfo for articles published from 2008 to 2013. Inclusion criteria were qualitative research articles published in English from across the world and in peer-reviewed journals. Literature reviews, conference abstracts and grey literature were excluded from this metasynthesis.Review methodsThe review consisted of a) comprehensive search, b) study classification, c) abstraction of findings, d) synthesis. Of the 4640 citations screened, 69 articles were included for this metasynthesis.Results69 unique articles from 44 countries were included. This metasynthesis takes into account the perspectives of at least 2263 HIV-positive participants (740 men, 1008 women, 78 transgender individuals and 437 unspecified sex) and 994 healthcare providers, family members and community members. The most salient barriers and facilitators to HIV linkage and retention in HIV care affirm ecological factors that are mostly beyond individual patients’ control. Triadic streams of influence concurrently affect care engagement that include a person’s psychological state upon diagnosis and their informational challenges (intrapersonal stream); one-on-one interactions with providers and their immediate community (social stream); and life demands, overall quality of care experiences and other structural barriers (cultural-attitudinal stream). Each stream’s influence on HIV care engagement varies at any given point to reflect an individual’s evolving and unique experiences with HIV infection throughout the illness trajectory.ConclusionThere is sufficient evidence that detail how to best link and retain patients in HIV care. Themes identified indicate going beyond individual-level factors and towards shifting attention and resources to systems that patients navigate. Forceful structural-level actions are needed to correct these long-identified barriers and enhance care engagement facilitators.     

Resource Document: Coordination of Pediatric Emergency Care in EMS Systems

Background: Citing numerous pediatric-specific deficiencies within Emergency Medical Services (EMS) systems, the Institute of Medicine (IOM) recommended that EMS systems appoint a pediatric emergency care coordinator (PECC) to provide oversight of EMS activities related to care of children, to promote the integration of pediatric elements into day-to-day services as well as local and/or regional disaster planning, and to promote pediatric education across all levels of EMS providers. Methods: A systematic review of the literature was undertaken to describe the evidence for pediatric coordination across the emergency care continuum. The search strategy was developed by the investigators in consultation with a medical librarian and conducted in OVID, Medline, PubMed, Embase, Web of Science, and CINAHL databases from January 1, 1983 to January 1, 2016. All research articles that measured a patient-related or system-related outcome associated with pediatric coordination in the setting of emergency care, trauma, or disaster were included. Opinion articles, commentaries, and letters to the editors were excluded. Three investigators independently screened citations in a hierarchical manner and abstracted data. Results: Of 149 identified titles, nine were included in the systematic review. The nine articles included one interventional study, five surveys, and three consensus documents. All articles favored the presence of pediatric coordination. The interventional study demonstrated improved documentation, clinical management, and staff awareness of high priority pediatric areas. Conclusion: The current literature supports the identification of pediatric coordination to facilitate the optimal care of children within EMS systems. In order for EMS systems to provide high quality care to children, pediatric components must be integrated into all aspects of care including day-to-day operations, policies, protocols, available equipment and medications, quality improvement efforts, and disaster planning. This systematic review and resource document serves as the basis for the National Association of EMS Physicians position statement entitled “Physician Oversight of Pediatric Care in Emergency Medical Systems.”     

Transition from children’s to adult services for young adults with life-limiting conditions: A realist review of the literature

BackgroundImprovements in care and treatment have led to more young adults with life-limiting conditions living beyond childhood, which means they must make the transition from children’s to adult services. This has proved a challenging process for both young adults and service providers, with complex transition interventions interacting in unpredictable ways with local contexts.ObjectivesTo explain how intervention processes interact with contextual factors to help transition from children’s to adult services for young adults with life-limiting conditions.DesignSystematic realist review of the literature.Data sourcesLiterature was sourced from four electronic databases: Embase, MEDLINE, Science Direct and Cochrane Library from January 1995 to April 2016. This was supplemented with a search in Google Scholar and articles sourced from reference lists of included papers.Review methodsData were extracted using an adapted standardised data extraction tool which included identifying information related to interventions, mechanisms, contextual influences and outcomes. Two reviewers assessed the relevance of papers based on the inclusion criteria. Methodological rigor was assessed using the relevant Critical Appraisal Skills Programme tools.Results78 articles were included in the review. Six interventions were identified related to an effective transition to adult services. Contextual factors include the need for children’s service providers to collaborate with adult service providers to prepare an environment with knowledgeable staff and adequate resources. Mechanisms triggered by the interventions include a sense of empowerment and agency amongst all stakeholders.ConclusionsEarly planning, collaboration between children’s and adult service providers, and a focus on increasing the young adults’ confidence in decision-making and engaging with adult services, are vital to a successful transition. Interventions should be tailored to their context and focused not only on organisational procedures but on equipping young adults, parents/carers and staff to engage with each other effectively.     

Rapid Deployment of Chiropractic Telehealth at 2 Worksite Health Centers in Response to the COVID-19 Pandemic: Observations from the Field

ObjectiveThe purpose of this paper is to describe the rapid deployment of telehealth, particularly real time video conference, for chiropractic services as a response to COVID-19.MethodsTwo health centers at 2 campuses of a large California corporation have chiropractic care integrated into physical medicine services. Care was suspended beginning on March 17, 2020 to prevent spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) among patients and staff. On March 19, the Governor of California issued a stay at home order. With musculoskeletal problems being common in the employee patient population, telehealth services were quickly developed to continue chiropractic care for patients. Using existing infrastructure, several members of the health center team developed chiropractic telehealth operations within 2 days.ResultsMusculoskeletal telehealth services included examinations, risk assessment, advice, and rehabilitative exercises. These telehealth visits facilitated care that would have otherwise been unavailable to employees. Patients reported that the appointments were helpful, addressed their concerns, and provided a safe method to see their doctor. Regular interprofessional teamwork and relations between the clinic operator and client company were key contributors to operationalizing this service in our integrated healthcare environment.ConclusionWe were able to quickly implement real time video conferencing and other forms of telehealth for chiropractic services at 2 worksite health centers. This paper includes information and insights to providers about setting up similar telehealth systems so they may also provide this benefit for patients in their communities during pandemics or disasters.     

Integrating Mental Health and Addictions Services to Improve Client Outcomes

Substance use disorders are highly prevalent among adults with mental health disorders. In many health service delivery areas, mental health and addictions services are delivered separately. However, current best practices indicate that integration of mental health and addictions services can lead to better outcomes for clients with co-occurring disorders, including fewer hospitalizations. Service integration in the community can occur in many ways, including full or partial program integration. While the delivery of mental health and addictions services must be responsive to the needs of the local community, fully integrated programs have the strongest evidence base for positive client outcomes.     

The Experience of Mental Health Service Use for African American Mothers and Youth

Little is known about African American families’ experiences with mental health services. A purposive sample of 40 dyads of African American youth (aged 13 to 19) and their mothers participated in a cross-sectional qualitative research design using semi-structured interviews that elicited information about their past experiences and satisfaction with mental health services. Though rarely received, group and family therapy were perceived favorably. However, both mothers and youth reported dissatisfaction centered on medication and lack of professionalism, confidentiality, and concern by providers. The failure of mental health services providers to meet basic standards of quality and professionalism may explain the low rate of service use by African Americans.     

Categorizing national caregiver recommendations to support family caregivers and address unmet needs

BackgroundRecognizing family caregivers as vital providers of long-term assistance to loved ones with chronic illness, several national organizations developed recommendations to improve support for family caregivers.PurposeThis article categorizes these recommendations to advance family-centered nursing practice, develop health policies, and advocate for family caregiver support.MethodsSix reports of caregiver recommendations published in the United States from 2016 to 2021 were analyzed using thematic analysis.FindingsThe 108 recommendations were organized into five categories: policy; caregiver assessment and support; health professional practices; public awareness; advance care planning.DiscussionEnsuring economic security, establishing a national data collection strategy, addressing caregivers’ diverse needs, improving access to health care and support services, and increasing public awareness were highlighted.ConclusionThe recommendations provide a roadmap for nurses at all levels of practice to advocate for a national agenda to develop, fund, and implement inclusive health care policies and interventions to address unmet caregiver needs and maximize support.     

Peer workers’ perceptions and experiences of barriers to implementation of peer worker roles in mental health services: A literature review

ObjectivesTo identify peer workers’ perceptions and experiences of barriers to implementation of peer worker roles in mental health services.DesignReview of qualitative and quantitative studies.Data sourcesA comprehensive electronic database search was conducted between October 2014 and December 2015 in PubMed, CINAHL, Web of Science, The Cochrane Library, and PsycARTICLES. Additional articles were identified through handsearch.Review methodsAll articles were assessed on quality. A thematic analysis informed by a multi-level approach was adopted to identify and discuss the main themes in the individual studies. Reporting was in line with the ‘Enhancing transparency in reporting the synthesis of qualitative research’ statement.ResultsEighteen articles met the inclusion criteria. All studies adopted qualitative research methods, of which three studies used additional quantitative methods. Peer workers’ perceptions and experiences cover a range of themes including the lack of credibility of peer worker roles, professionals’ negative attitudes, tensions with service users, struggles with identity construction, cultural impediments, poor organizational arrangements, and inadequate overarching social and mental health policies.ConclusionsThis review can inform policy, practice and research from the unique perspective of peer workers. Mental health professionals and peer workers should enter into an alliance to address barriers in the integration of peer workers and to enhance quality of service delivery. Longitudinal research is needed to determine how to address barriers in the implementation of peer worker roles.     

Self-reported competence in long term care provision for adult cancer survivors: A cross sectional survey of nursing and allied health care professionals

BackgroundCancer survival is increasing as patients live longer with a cancer diagnosis. This success has implications for health service provision in that increasing numbers of adults who have received cancer therapy are requiring monitoring and long-term health care by a wide range of practitioners. Given these recent trends there is a need to explore staff perceptions and confidence in managing the consequences of cancer diagnosis and treatment in cancer survivors to enhance an integrated cancer service delivery.ObjectiveThis study examines the self-reported perceptions of competence in nurses and professionals allied to medicine providing survivorship services caring for adults after cancer treatment in both secondary and primary care.DesignA cross sectional survey of the adult cancer workforce using a self-assessment tool for assessing confidence in providing long-term cancer patient management. This study was a health service evaluation.SettingThe study was conducted within the United Kingdom.ParticipantsRespondents were 618 health care professionals of these 368 were specialist adult cancer nurses in oncology and the community setting and 250 cancer allied health professionals.MethodThe survey tool was developed with experts in cancer management, nurses professionals allied to medicine such as physiotherapists and dieticians, educationalists, patient groups as well as health service managers. Competence was assessed in 4 domains clinical practice, symptom management, care co-ordination and proactive management. Perceptions of training needs were also ascertained. Data were collected using an Internet survey distributed through cancer services, community settings and professional institutions.ResultsIn total 618 practitioners who responded were providing services for adults’ 1-year post cancer therapy. Practitioners felt confident in managing psychosocial care and communicating with patients. Deficits in self-reported confidence were found in long-term medications management, care planning, long-term and complex symptom management, for those providing dimensions of care coordination and proactive care. Differences in confidence were seen between practitioner groups. Community nurses felt less skilled in managing adult cancer patients long-term.ConclusionsNurses and allied health professionals self-reported confidence, in managing all areas of care for adult cancer survivors, is variable with deficits in important areas of practice. Despite this being a small proportion of practitioners who are working in cancer care, those responding had perceived gaps in knowledge and educational needs. In providing cancer aftercare there is a requisite shift to proactive care, supported self-management and collaborative management if patient's long-term consequences of cancer and its treatment are to be addressed.Implications for practiceIf health care providers are to transform cancer survivor services then investment is required in education and capability planning across nurses, allied health professionals in both the hospital and the community setting.     

EMS Provider Determinations of Necessity for Transport and Reimbursement for EMS Response,Medical Care,and Transport: Combined Resource Document for the National Association of EMS Physicians Position Statements

Abstract

With increasing demands for emergency medical services (EMS), many EMS jurisdictions are utilizing EMS provider-initiated nontransport policies as a method to offload potentially nonemergent patients from the EMS system. EMS provider determination of medical necessity, resulting in nontransport of patients, has the potential to avert unnecessary emergency department visits. However, EMS systems that utilize these policies must have additional education for the providers, a quality improvement process, and active physician oversight. In addition, EMS provider determination of nontransport for a specific situation should be supported by evidence in the peer-reviewed literature that the practice is safe. Further, EMS systems that do not utilize these programs should not be financially penalized. Payment for EMS services should be based on the prudent layperson standard. EMS systems that do utilize nontransport policies should be appropriately reimbursed, as this represents potential cost savings to the health care system.     

Disability rights in the context of HIV and AIDS: a critical review of nineteen Eastern and Southern Africa (ESA) countries

Purpose: Many Eastern and Southern African (ESA) states are obliged to review and amend their legal frameworks with regards to disability since signing and ratifying the UN Convention on the Rights of Persons with Disabilities (CRPD). The HIV epidemic is one of the main health concerns in the region and is becoming increasingly associated with causing disabilities. In addition, people with disabilities are particularly at risk of exposure to HIV. Despite this, HIV programming has not yet included the interrelationship of disability and HIV. The principles within the CRPD may create much-needed international pressure and so provide a platform for the integration and inclusion of disability into HIV policies and programs. Method: This paper is based on a review of the legal framework in relation to HIV and disability in 19 ESA countries. It identifies 12 key articles of the Convention, which are particularly relevant to the interrelationship of HIV and disability. The paper assesses how these are integrated in the region’s disability or HIV legal frameworks and identifies the main gaps within these legal systems. Results: While many country’s constitutions, disability and HIV laws protect certain key rights, such as the rights to equality and nondiscrimination, employment and health, there are clear gaps in the legal responses to disability and HIV. In particular, legal frameworks fail to provide adequately for accessibility, mobility and access to justice and protection from violence for people with disabilities. This results in limited protection for people with disabilities from HIV exposure and access to services to address HIV-related health and welfare needs. Conclusions: The paper identifies the gaps and makes recommendations for implementing steps toward the integration of disability into HIV-related laws, policies and programs.

Implications for Rehabilitation

• Rehabilitation in Eastern and Southern Africa has to cater for an increasing number of people living with HIV who experience disability.

• The legal obligation of Article 25 in the Convention on the Rights of Persons with Disabilities (CRPD) obliges African states to provide appropriate rehabilitation and access to health care services for people with disabilities.

     

Factors Associated With Success in Reducing HIV Mother-to-child Transmission in Sub-Saharan Africa: Interviews With Key Stakeholders

PurposeA key global health challenge is the persistence of new pediatric HIV infections due to mother-to-child transmission (MCTC), particularly in sub-Saharan Africa. The purpose of this study was to identify the key strategies that some sub-Saharan African countries have used to successfully reduce new pediatric HIV infections.MethodsA qualitative study utilizing semistructured interviews with key stakeholders in 6 sub-Saharan African countries (Burundi, Malawi, Mozambique, South Africa, Swaziland, and Uganda) was conducted from September 2017 to September 2018. These stakeholders were situated in the National Department of Health or in international health-funding bodies relating to the provision of the HIV/AIDS implementation program in these countries. The countries were selected based on considerable success achieved with HIV treatment in pregnant women. Audio-recorded interviews were transcribed verbatim and thematic analysis was undertaken.FindingsIn all, 6 interviews were conducted, and the mean time of the interviews was 62 min. There were similar numbers of men and women, and most were in the 35- to 45-year age group. Five in six were either a medical doctor or held a doctorate degree. Four in six had >10 years of experience working in the prevention of HIV (PMTCT). Four key strategies that contributed to significant reductions in pediatric HIV infection in the respective countries were identified: (1) committed political leadership; (2) support structures within the community; (3) innovation in service delivery; and (4) robust monitoring and evaluation systems. Stakeholders spoke about how their governments played a leading role in engagement with communities, and in the dissemination of services. Innovative service delivery comprising task-shifting initiatives and the integration of maternal, newborn, and child health and HIV PMCTC services played an important role in reducing the burdens experienced by women and health care workers, leading to improved health outcomes. Peer support also helped mothers to adhere to their treatment during and after pregnancy. The capacity of national programs to monitor and evaluate the PMTCT services and the importance of regular viral-load monitoring were highlighted by the stakeholders.ImplicationsThese strategies can be reviewed for possible implementation by other sub-Saharan African countries as possible means of reducing new pediatric HIV infections.     

Palliative Care Research in Africa: Consensus Building for a Prioritized Agenda

ContextPalliative care research in Africa is in its relative infancy, with dedicated financial support extremely limited. Therefore, setting research priorities to optimize use of limited resources is imperative.ObjectivesTo develop a prioritized research agenda for palliative care in Africa.MethodsWe used a two-stage process involving palliative care professionals and researchers: 1) generation of an initial topic list at a consultative workshop of experts and 2) prioritization of that list using a consensus development process, the nominal group technique.ResultsPhase 1: 41 topics were generated across five groups, with several topics nominated in more than one group. Phase 2: 16 topics and three broad thematic areas were identified. The two most prioritized topics within each of the three themes were the following: Theme 1: patient, family, and volunteers—1) care outcomes and the impact of palliative care as perceived by patients and caregivers and 2) palliative care needs of children; Theme 2: health providers—1) impact of palliative care training on care and practice and 2) integration of palliative care and antiretroviral therapy services; and Theme 3: health systems—1) palliative care needs assessments at the micro-, meso-, and macro-levels and 2) integration of palliative care into health systems and educational curricula.ConclusionConsensus-based palliative care topics determined by the study can assist researchers in optimizing limited research capacities by focusing on these prioritized areas. Subsequent to the identification and publication of the research agenda, concrete steps will be undertaken by the African Palliative Care Research Network and other partners to help implement it.     

Hospital–community interface: A qualitative study on patients with cancer and health care providers' experiences

BackgroundPatients with cancer must deal with complex and fragmented healthcare systems in addition to coping with the burden of their illness. To improve oncology treatment along the care continuum, the barriers and facilitators for streamlined oncologic care need to be better understood.PurposeThis study sought to gain insight into the hospital–community interface from the point of view of patients with cancer, their families, and health care providers on both sides of the interface i.e., the community and hospital settings.Methods and sampleThe sample comprised 37 cancer patients, their family members, and 40 multidisciplinary health care providers. Twelve participants were interviewed individually and 65 took part in 10 focus groups. Based on the grounded theory approach, theoretical sampling and constant comparative analyses were used.ResultsTwo major concepts emerged: “ambivalence and confusion” and “overcoming healthcare system barriers.” Ambiguity was expressed regarding the roles of health care providers in the community and in the hospital. We identified three main strategies by which these patients and their families overcame barriers within the system: patients and families became their own case managers; patients and health care providers used informal routes of communication; and nurse specialists played a significant role in managing care.ConclusionsThe heavy reliance on informal routes of communication and integration by patients and providers emphasizes the urgent need for change in order to improve coordinating mechanisms for hospital–community oncologic care.     

Unaccompanied Refugee Minors in Sweden: Challenges in Residential Care and the Role of Professional Social Work

ABSTRACT

In 2015, 35,369 unaccompanied refugee minors (URMs) applied for asylum in Sweden, making it the number one destination country for URMs in Europe. URMs often face multiple social problems and mental health issues that can be the result of stressful pre-migration experiences, the migration experience itself, and integration challenges in Europe. Drawing on grey as well as peer-reviewed literature, this paper aims to provide insight into how Sweden deals with the reception of URMs in general, and which challenges social service systems faced during the height of the “European Migration Crisis in 2015.“ Particular focus is placed on the role of residential care settings in providing accommodation and care for URMs. A synthesis of the literature suggests that although Sweden can be seen as a country with long-standing experience in receiving migrants, the influx of migrants has challenged the welfare state in keeping its high standard of social support for URMs and maintaining the quality of professional social work interventions. Nonetheless, considerable efforts have been made to adapt existing services and create new psychosocial interventions.     

Barriers to accessing safe motherhood and reproductive health services: the situation of women with disabilities in Lusaka,Zambia

Purpose:?To ascertain how well health services in Lusaka, Zambia currently meet the safe motherhood and reproductive health care needs of women who have physical impairment leading to disability.

Methods:?A qualitative study was conducted in Lusaka, Zambia. In-depth tape-recorded interviews were conducted with 24 purposively selected women with disabilities and with 25 safe motherhood/reproductive public sector health service providers. Qualitative analysis was conducted using NVivo software.

Results:?Women with disabilities encounter various social, attitudinal and physical barriers to accessing safe motherhood and reproductive health (RH) services in this particular setting. The strong desire for children and affection can increase vulnerability to sexual exploitation. At the same time, a generalized assumption among reproductive health service providers that women with disabilities will not be sexually active, and not require RH services, leads to increased vulnerability to sexually transmitted infection including HIV. Once pregnant, traditional beliefs about transmission of disabilities can create barriers to integration in ante-natal clinics. Nurse-midwives' fear of delivery complications in women with physical impairments can also result in routine over-referral to a tertiary maternity facility which is outside the locality and harder for women with mobility limitations to get to.

Conclusion:?Greater understanding of the influences underpinning societal attitudes towards sexuality and disability in this setting, and more extensive communication between health care staff and women with disabilities would facilitate positive action towards improving safe motherhood and reproductive health services for women with disabilities.     

Contending With Advanced Illness: Patient and Caregiver Perspectives

ContextDespite improvements in end-of-life care, some unrelieved suffering persists for patients with advanced illness and their family members. Hospice and palliative care services can reduce suffering, but these services remain under-used.ObjectivesTo investigate how patients with advanced illness and their primary caregivers experienced and responded to health care needs and decision making and how some dyads moved toward comfort-focused care.MethodsThis was a qualitative study using the grounded theory method for sample selection, data collection, and analysis. Dyadic semi-structured interviews were audio-recorded and transcribed for analysis. Twenty-two participants, 12 patients and 10 family surrogates, provided 16 interviews for this study.ResultsParticipants engaged in a process of contending with advanced illness. The major phases comprising this process were suffering, struggling, and settling. Struggling included enduring the experience and fighting the illness. During the phase of settling, the focus shifted away from curative efforts and toward supportive care. Conditions that facilitated the movement into this phase included receiving clear and consistent information about the patient's health status, trusting health care providers, having attended to advance care planning in some form, and being aware of and able to acknowledge the terminal nature of the illness.ConclusionFindings from this pilot study offer a preliminary theoretical model to enhance the understanding of patient and family caregiver needs during advanced illness. Awareness of their perspective can inform the timing and content of clinicians' communication and interventions.