Research evidence on strategies enabling integration of electronic health records in the health care systems of low‐ and middle‐income countries: A literature review

Integration of electronic health records (EHRs) in the national health care systems of low‐ and middle‐income countries (LMICs) is vital for achieving the United Nations Sustainable Development Goal of ensuring healthy lives and promoting well‐being for all people of all ages. National EHR systems are increasing, but mostly in developed countries. Besides, there is limited research evidence on successful strategies for ensuring integration of national EHRs in the health care systems of LMICs. To fill this evidence gap, a comprehensive survey of literature was conducted using scientific electronic databases—PubMed, SCOPUS, Web of Science, and Global Health—and consultations with international experts. The review highlights the lack of evidence on strategies for integrating EHR systems, although there was ample evidence on implementation challenges and relevance of EHRs to vertical disease programs such as HIV. The findings describe the narrow focus of EHR implementation, the prominence of vertical disease programs in EHR adoption, testing of theoretical and conceptual models for EHR implementation and success, and strategies for EHR implementation. The review findings are further amplified through examples of EHR implementation in Sierra Leone, Malawi, and India. Unless evidence‐based strategies are identified and applied, integration of national EHRs in the health care systems of LMICs is difficult.     

Better Measurement for Performance Improvement in Low‐ and Middle‐Income Countries: The Primary Health Care Performance Initiative (PHCPI) Experience of Conceptual Framework Development and Indicator Selection

Policy Points:

• Strengthening accountability through better measurement and reporting is vital to ensure progress in improving quality primary health care (PHC) systems and achieving universal health coverage (UHC).
• The Primary Health Care Performance Initiative (PHCPI) provides national decision makers and global stakeholders with opportunities to benchmark and accelerate performance improvement through better performance measurement.
• Results from the initial PHC performance assessments in low‐ and middle‐income countries (LMICs) are helping guide PHC reforms and investments and improve the PHCPI's instruments and indicators. Findings from future assessment activities will further amplify cross‐country comparisons and peer learning to improve PHC.
• New indicators and sources of data are needed to better understand PHC system performance in LMICs.

Context

The Primary Health Care Performance Initiative (PHCPI), a collaboration between the Bill and Melinda Gates Foundation, The World Bank, and the World Health Organization, in partnership with Ariadne Labs and Results for Development, was launched in 2015 with the aim of catalyzing improvements in primary health care (PHC) systems in 135 low‐ and middle‐income countries (LMICs), in order to accelerate progress toward universal health coverage. Through more comprehensive and actionable measurement of quality PHC, the PHCPI stimulates peer learning among LMICs and informs decision makers to guide PHC investments and reforms. Instruments for performance assessment and improvement are in development; to date, a conceptual framework and 2 sets of performance indicators have been released.

Methods

The PHCPI team developed the conceptual framework through literature reviews and consultations with an advisory committee of international experts. We generated 2 sets of performance indicators selected from a literature review of relevant indicators, cross‐referenced against indicators available from international sources, and evaluated through 2 separate modified Delphi processes, consisting of online surveys and in‐person facilitated discussions with experts.

Findings

The PHCPI conceptual framework builds on the current understanding of PHC system performance through an expanded emphasis on the role of service delivery. The first set of performance indicators, 36 Vital Signs, facilitates comparisons across countries and over time. The second set, 56 Diagnostic Indicators, elucidates underlying drivers of performance. Key challenges include a lack of available data for several indicators and a lack of validated indicators for important dimensions of quality PHC.

Conclusions

The availability of data is critical to assessing PHC performance, particularly patient experience and quality of care. The PHCPI will continue to develop and test additional performance assessment instruments, including composite indices and national performance dashboards. Through country engagement, the PHCPI will further refine its instruments and engage with governments to better design and finance primary health care reforms.     

Contextual factors affecting health information system strengthening

At the turn of the century, several major efforts were initiated to combat HIV/AIDS and other major epidemics affecting low- and middle-income countries (LMICs). They were accompanied by initiatives to enable recipient countries to collect and use data to guide their public health programmes. These health information systems (HIS) typify systems in that they have multiple interacting components, and they are embedded within larger systems. Components of a larger system act as the context for all lower-level systems. Their effects can be pervasive, and thus be taken for granted or regarded as unchangeable. We identify four contextual factors that affect efforts to strengthen HIS: hierarchical roles, aid funding, corruption, and competing priorities. We provide examples of each as experienced by those working to strengthen HIS in LMICs. Each of these contextual factors can seriously diminish the effectiveness of HIS strengthening efforts and their long-term sustainability. We propose research questions about each that would enable those engaged in HIS strengthening to work effectively and sustainably.     

Here comes the SUN: Self‐assessed unmet need,worsening health outcomes,and health care inequity

Utilization‐based approaches have predominated the measurement of socioeconomic‐related inequity in health care. This approach, however, can be misleading when preferences over health and health care are correlated with socioeconomic status, especially when the underlying focus is on equity of access. We examine the potential usefulness of an alternative approach to assessing inequity of access using a direct measure of possible barriers to access—self‐reported unmet need (SUN)—which is documented to vary with socioeconomic status and is commonly asked in health surveys. Specifically, as part of an assessment of its external validity, we use Canadian longitudinal health data to test whether self‐reported unmet need in one period is associated with a subsequent deterioration in health status in a future period, and find that it is. This suggests that SUN does reflect in part reduced access to needed health care, and therefore may have a role in assessing health system equity as a complement to utilization‐based approaches.     

Indigenous health program evaluation design and methods in Australia: a systematic review of the evidence

Objective: Indigenous Australians experience a disproportionately higher burden of disease compared to non‐Indigenous Australians. High‐quality evaluation of Indigenous health programs is required to inform health and health services improvement. We aimed to quantify methodological and other characteristics of Australian Indigenous health program evaluations published in the peer‐reviewed literature. Methods: Systematic review of peer‐reviewed literature (November 2009–2014) on Indigenous health program evaluation. Results: We identified 118 papers describing evaluations of 109 interventions; 72.0% were university/research institution‐led. 82.2% of evaluations included a quantitative component; 49.2% utilised quantitative data only and 33.1% used both quantitative and qualitative data. The most common design was a before/after comparison (30.5%, n=36/118). 7.6% of studies (n=9/118) used an experimental design: six individual‐level and three cluster‐randomised controlled trials. 56.8% (67/118) reported on service delivery/process outcomes (versus health or health risk factor outcomes) only. Conclusions: Given the number of Indigenous health programs that are implemented, few evaluations overall are published in the peer‐reviewed literature and, of these, few use optimal methodologies such as mixed methods and experimental design. Implications for public health: Multiple strategies are required to increase high‐quality, accessible evaluation in Indigenous health, including supporting stronger research‐policy‐practice partnerships and capacity building for evaluation by health services and government.     

Medical Abortion Provision by Pharmacies and Drug Sellers in Low‐ and Middle‐Income Countries: A Systematic Review

We undertook a systematic review to assess 1) the level and quality of pharmacy and drug shop provision of medical abortion (MA) in low‐ and middle‐income countries (LMICs) and 2) interventions to improve quality of provision. We used standardized terms to search six databases for peer‐reviewed and grey literature. We double‐extracted data using a standardized template, and double‐graded studies for methodological quality. We identified 22 studies from 16 countries reporting on level and quality of MA provision through pharmacies and drug sellers, and three intervention studies. Despite widespread awareness and provision of MA drugs, even in legally restricted contexts, most studies found that pharmacy workers and drug sellers had poor knowledge of effective regimens. Evidence on interventions to improve pharmacy and drug shop provision of MA was limited and generally low quality, but indicated that training could be effective in improving knowledge. Programmatic attention should focus on the development and rigorous evaluation of innovative interventions to improve women's access to information about MA self‐management in low‐and middle‐income countries.     

Complementary and alternative medicine in rural communities: current research and future directions

Contexts: The consumption of complementary and alternative medicine (CAM) in rural areas is a significant contemporary health care issue. An understanding of CAM use in rural health can provide a new perspective on health beliefs and practice as well as on some of the core service delivery issues facing rural health care generally. Purpose: This article presents the first review and synthesis of research findings on CAM use and practice in rural communities. Methods: A comprehensive search of literature from 1998 to 2010 in CINAHL, MEDLINE, AMED, and CSA Illumina (social sciences) was conducted. The search was confined to peer‐reviewed articles published in English reporting empirical research findings on the use or practice of CAM in rural settings. Findings: Research findings are grouped and examined according to 3 key themes: “prevalence of CAM use and practice,”“user profile and trends of CAM consumption,” and “potential drivers and barriers to CAM use and practice.” Conclusions: Evidence from recent research illustrates the substantial prevalence and complexity of CAM use in rural regions. A number of potential gaps in our understanding of CAM use and practice in rural settings are also identified.     

Impact of COVID‐19 on access to healthcare in low‐ and middle‐income countries: Current evidence and future recommendations

The COVID‐19 pandemic continues to be a major public health threat globally and low‐ and middle‐income countries (LMICs) are not an exception. The impact of the COVID‐19 pandemic is far‐reaching on many areas including but not limited to global health security, economic and healthcare delivery with a potential impact on access to healthcare in LMICs. We evaluate the impact of the COVID‐19 pandemic on access to healthcare in LMICs, as well as plausible strategies that can be put in place to ensure that the delivery of healthcare is not halted. In order to mitigate the devastating effect of the COVID‐19 pandemic on the already weak health systems in LMICs, it is much necessary to reinforce and scale up interventions and proactive measures that will ensure that access to healthcare is not disrupted even in course of the pandemic.     

The performance and potential of the Australasian Health Star Rating system: a four‐year review using the RE‐AIM framework

Objective : The Health Star Rating (HSR) is a front‐of‐pack nutrition labelling system, implemented voluntarily in Australia and New Zealand since 2014. Our aim was to evaluate HSR's performance. Method : We used data from peer‐reviewed publications and government‐commissioned monitoring and evaluation, websites and communiqués to evaluate HSR's performance between June 2014 and October 2018 using the RE‐AIM (Reach, Efficacy, Adoption, Implementation and Maintenance) framework. Results : Thirty‐three peer‐reviewed publications, 21 government and three independent reports informed the assessment. Awareness and trust in HSR was increasing, though campaign reach remained low. Consumers liked, could understand and use the HSR logo, though effects on purchasing were largely unknown. The algorithm was the focus of a formal review. HSR was present on 20–28% of products but biased to those that scored better (HSR≥3.0). Necessary stakeholders were mostly engaged. Conclusions : A substantial body of work supports continuation and strengthening of HSR. Reasonable refinements to HSR's star graphic and algorithm, action to initiate mandatory implementation, and strengthened HSR governance present the clearest opportunities for improving public health impact. Implications for public health : Development and implementation of government‐led front‐of‐pack nutrition labelling systems have the potential to improve public health, while engaging a diverse set of stakeholders.     

Transnational tobacco companies and the mechanism of externalization: A realist synthesis

Externalization theory assumes that risks and costs are systematically displaced from high-income countries (HICs) to low- and middle-income countries (LMICs). We review how and why transnational tobacco companies (TTCs) influence the local circumstances of LMICs that trigger externalization mechanisms, leading to tobacco-attributable risk outcomes. Our realist synthesis of scientific evidence and gray literature identifies externalization mechanisms with risk outcomes at the level of health policy, smoking trends, and tobacco production. The results reveal the mediating role of local and global third parties and intermediaries. Externalization mechanisms produce systematic tobacco-attributable inequalities between places located in HICs and those located in LMICs.     

Zinc deficiency in low‐ and middle‐income countries: prevalence and approaches for mitigation

This review addresses the prevalence of zinc deficiency in Low‐ and Middle‐income Countries (LMICs) and assesses the available strategies for its alleviation. The paucity of national‐level data on the zinc deficiency in LMICs is partially a result of the lack of a reliable biomarker. Zinc deficiency appears to be a public health problem in almost all the LMICs, irrespective of the recommended indicators (plasma zinc concentration, dietary zinc adequacy and stunting prevalence) used. Based on plasma/serum zinc concentration (PZC), which is the most appropriate indicator at present, the prevalence of zinc deficiency in LMICs is of concern. Among the 25 countries for which national PZC data were available, 23 had a zinc deficiency prevalence of >20% for at least one physiological group. Zinc supplementation is largely restricted as an adjunct therapy for diarrhoea management in children, and the best platform and the most effective way of preventive zinc supplementation delivery remains to be established. Impact assessment for current zinc fortification programmes in LMICs and the effectiveness of zinc supplementation as part of a multi‐micronutrient powder is to be determined. Dietary diversification, though promising for LMICs, is in the nascent stages of development at present. Inclusion of meat and animal products can be an important way of improving zinc status. Programmatic experience with the promotion of home processing techniques to increase absorbable zinc in the diet is lacking. Conventional biofortification techniques are gaining recognition in LMICs; however, transgenic biofortification as a strategy remains controversial.     

Interventions to improve adolescents' contraceptive behaviors in low- and middle-income countries: a review of the evidence base

Objective (s)

Many adolescents in developing countries have an unmet need for contraception, which can contribute to poor reproductive health outcomes. Recent literature reviews have not adequately captured effective contraceptive services and interventions for adolescents in low- and middle-income countries (LMICs). This study aims to identify and evaluate the existing evidence base on contraceptive services and interventions for adolescents in LMICs that report an impact on contraceptive behavior outcomes.

Study Design

Structured literature review of published and unpublished papers about contraceptive services and interventions for adolescents in LMICs that report an impact on contraceptive behavior outcomes.

Results

We identify common elements used by programs that measured an impact on adolescent contraceptive behaviors and summarize outcomes from 15 studies that met inclusion criteria. Effective programs generally combined numerous program approaches and addressed both user and service provision issues. Overall, few rigorous studies have been conducted in LMICs that measure contraceptive behaviors. Few interventions reach the young, the out of school and other vulnerable groups of adolescents.

Conclusion (s)

Though the evidence base is weak, there are promising foundations for adolescent contraceptive interventions in nearly every region of the world. We offer recommendations for programmers and identify gaps in the evidence base to guide future research.     

Factors limiting data quality in the expanded programme on immunization in low and middle-income countries: A scoping review

Few public health interventions can match the immense achievements of immunization in terms of mortality and morbidity reduction. However, progress in reaching global coverage goals and achieving universal immunization coverage have stalled; with key stakeholders concerned about the accuracy of reported coverage figures. Incomplete and incorrect data has made it challenging to obtain an accurate overview of immunization coverage, particularly in low- and middle-income countries (LMIC).To date, only one literature review concerning immunization data quality exists. However, it only included articles from Gavi-eligible countries, did not go deep into the characteristics of the data quality problems, and used a narrow ‘data quality’ definition. This scoping review builds upon that work; exploring the “state of data quality” in LMIC, factors affecting data quality in these settings and potential means to improve it.Only a small volume of literature addressing immunization data quality in LMIC was found and definitions of ‘data quality’ varied widely. Data quality was, on the whole, considered poor in the articles included. Coverage numerators were seen to be inflated for official reports and denominators were inaccurate and infrequently adjusted. Numerous factors related to these deficiencies were reported, including health information system fragmentation, overreliance on targets and poor data management processes. Factors associated with health workers were noted most frequently. Authors suggested that data quality could be improved by ensuring proper data collection tools, increasing workers’ capacities and motivation through training and supervision, whilst also ensuring adequate and timely feedback on the data collected.The findings of this scoping review can serve as the basis to identify and address barriers to good quality immunization data in LMICs. Overcoming said barriers is essential if immunization’s historic successes are to continue.     

Forty years of USAID health cooperation in Bolivia. A lose–lose game?

The present article proposes an analysis of the USA–Bolivia relationships in the health sector between 1971 and 2010 based on a grey and scientific literature review and on interviews. We examined United States Agency for International Development (USAID) interventions, objectives, consistency with Bolivian needs, and impact on health system integration. USAID operational objectives—decentralization, fertility and disease control, and maternal and child health—may have worked against each other while competing for limited Ministry of Health resources. They largely contributed to the segmentation and fragmentation of the Bolivian health system. US cooperation in health did not significantly improve health status while the USAID failed to properly tackle anti‐drugs, political, and economic US interests in Bolivia. Copyright © 2012 John Wiley & Sons, Ltd.     

Predictors of Adolescent Sexual Behavior and Intention: A Theory-Guided Systematic Review

PurposeTo better understand why adolescents initiate sexual activity at early ages, we conducted a systematic literature review guided by eight key elements outlined in an integrative theoretical framework.MethodsUsing the matrix method for literature reviews, we extracted—from 69 published studies—statistically significant and nonsignificant findings (related to the attempted prediction/explanation of adolescents’ sexual behavior and intention) and organized them using the various integrative model elements. We also assessed these publications’ methodological quality including each study’s deployment of theory, appropriate design, and data analytic/reporting techniques.ResultsThree integrative theoretical framework elements—intention, perceived norms, and an environmental constraint variable, time home alone—emerged as stable predictors of sexual behavior outcomes in this body of literature. This analysis revealed, however, a literature that has remained rather stagnant regarding its methodological quality, over time.ConclusionsImplications for adolescent sexual health promotion practice and research are discussed.     

The stipulation‐stimulation spiral: A model of system change

This paper proposes a general model, based on what is known about the nature of (complex) systems, of how systems—in particular, health care systems—respond to attempted change. Inferences are drawn from a critical literature review and reinterpretation of two primary studies. The two fundamental system‐change approaches are “stipulation” and “stimulation”: stip(ulation) attempts to elicit a specific response from the system; stim(ulation) encourages the system to generate diverse responses. Each has a unique strength: stip's is precision, the ability to directly impact the desired outcome and only that outcome; stim's is resonance, the ability to take advantage of behavior already present within the system. Each approach's inherent strength is its complement's inherent weakness; thus, stip and stim often clash if attempted simultaneously but can reinforce each other if applied in alternation. Opposite patterns (the “stip‐stim spiral” vs “stip‐stim stalemate”) are observed to underpin successful vs failed system change: The crucial difference is whether decision‐makers respond to a need for precision/resonance by strengthening the appropriate approach (stipulation/stimulation, respectively), or merely by weakening its complement. With further validation, the model has the potential to yield a more fundamental understanding of why system‐change efforts fail and how they can succeed.     

An Evaluation of Overcoming Barriers to Engage Consumers in the Use of Health Care Information Technology

The purpose of this review is to determine why consumers may not be adopting or engaging in the use of health information technology to successfully improve or maintain their health status. A literature search was completed to find articles related to consumer engagement in the use of health information technology. The literature found was then categorized based on a patient engagement framework defined by the National eHealth Collaborative. The barriers to engagement, issues with types of technology, and problems in study methodology were then synthesized for understanding consumer engagement. The results of the review showed the major barriers related to engaging consumers in the use of health information technology, including privacy, education, cost, literacy, accuracy of information, trust, meeting consumer needs, measures, integration, and policy. The most prevalent of these issues is that health information technology is often not designed with accurate and detailed user requirements in mind. Issues of the methodologies used to show how consumer health information technology is consumed relate to studies that are not aligned with the original purpose of the experiment. Additional work and research is needed to ensure that the design of consumer health information technology meets the consumer’s needs. Improved designs and methods of achieving these designs will create technology that consumers find appealing to use in order to better manage their health. If consumers find value in the technology, they will be more likely to engage and adopt it for additional use.     

天津市卫生人力资源与医学教育发展研究

目的:分析天津市居民卫生服务需求及卫生人力资源供求状况,为医学教育改革与发展提供科学参考。方法:采用文献查阅、抽样调查及专家访谈等方法进行研究,利用SPSS 13.0进行数据处理。结果:天津卫生人力数量充足,但存在教育层次偏低、整体素质不高及分布不均等问题。结论:建议提高医学教育层次、调整专业结构、优化教育模式及培养全科医生。     

Global tobacco prevention and control in relation to a cardiovascular health promotion and disease prevention framework: A narrative review

The purpose of this review is to emphasize the role of tobacco prevention and control in cardiovascular health (CVH) promotion and cardiovascular disease (CVD) prevention, including the importance of these endpoints for measuring the full impact of tobacco-related policies, programs, and practices. In this review, we describe an overview of tobacco control interventions that have led to substantial declines in tobacco use and the relationship between these declines with CVH and CVD. We review interventions that have had success in high-income countries (HICs) as well as those that are gaining traction in low- and middle-income countries (LMICs). We emphasize the challenges to comprehensive tobacco prevention and control strategies faced by LMICs, and highlight the special role of cardiovascular health professionals in achieving CVH promotion and CVD prevention endpoints through tobacco control. Tobacco prevention and control strategies have a strong scientific basis, yet a distinct gap remains between this evidence and implementation of tobacco control policies, particularly in LMICs. Health professionals can contribute to tobacco control efforts, especially through patient-level clinical interventions, when supported by a health care system and government that recognize and support tobacco control as a critical strategy for CVH promotion and CVD prevention. Understanding, supporting, and applying current and evolving policies, programs, and practices in tobacco prevention and control is the province of all health professionals, especially those concerned with CVH promotion and CVD prevention. A new tobacco control roadmap from the World Heart Federation provides a strong impetus to the needed interdisciplinary collaboration.