A Team-Based Approach to Introduce and Sustain the Use of the WHO Surgical Safety Checklist in Tanzania

Introduction

Millions of patients worldwide suffer disability and death due to complications related to surgery. Many of these complications can be reduced by the use of the World Health Organization (WHO) Surgical Safety Checklist (SSC), a simple tool that can enhance teamwork and communication and improve patient safety. Despite the evidence on benefits of its use, introducing and sustaining the use of the checklist are challenging. We present a team-based approach employed in a low-resource setting in Tanzania, which resulted in high checklist utilization and compliance rates.

Methods

We reviewed reported data from facility registers supplemented by direct observation data by mentors to evaluate the use of the WHO SSC across 40 health facilities in two regions of Tanzania between January and December 2018. We analyzed the self-reported monthly data on total number of major surgeries performed and proportion of surgeries where the checklist was used. We also analyzed the use of the SSC during direct observation by external mentors and completion rates of the SSC in a random selection of patient files during two mentorship visits between June and December 2018.

Results

During the review period, the average self-reported checklist utilization rate was 79.3% (11,564 out of 14,580 major surgeries). SSC utilization increased from 0% at baseline in January 2018 to 98% in December 2018. The proportion of checklists that were completely and correctly filled out increased between the two mentor visits from 82.1 to 92.8%, but the gain was significantly greater at health centers than at hospitals (p < 0.05). Health centers (which had one or two surgical teams) self-reported a higher checklist utilization rate than hospitals (which had multiple surgical teams), i.e., 99.4% vs 68.8% (p < 0.05).

Conclusion and recommendations

Our findings suggest that Surgical Safety Checklist implementation is feasible even in lower-resource settings. The self-reported SSC utilization rate is higher than reported in other similar settings. We attribute this finding to the team-based approach employed and the ongoing regular mentorship. We recommend use of this approach to scale-up checklist use in other regions in the country as recommended in the Ministry of Health of Tanzania’s National Surgical, Obstetric, and Anesthesia Plan (NSOAP).

     

A case study on building capacity to improve clinical mentoring and maternal child health in rural Tanzania: the path to implementation

Background

Tanzania is a low income, East African country with a severe shortage of human resources for health or health workers. This shortage threatens any gains the country is making in improving maternal health outcomes. This paper describes a partnership between Touch Foundation and NYU Rory Meyers College of Nursing - Global, aimed at improving clinical mentorship and capacity among nurses and midwives at two rural hospitals in the Tanzanian Lake Zone Region. Clinical mentoring capacity building and supportive supervision of staff has been shown to be a facilitator of retaining nurses and would be possible to acquire and implement quickly, even in a context of low resources and limited technology.

Methods

A case study approach structures this program implementation analysis. The NYU Meyers team conducted a 6-day needs assessment at the two selected hospitals. A SWOT analysis was performed to identify needs and potential areas for improvement. After the assessment, a weeklong training, tailored to each hospitals’ specific needs, was designed and facilitated by two NYU Meyers nursing and midwifery education specialists. The program was created to build on the clinical skills of expert nurse and midwife clinicians and suggested strategies for incorporating mentoring and preceptorship as a means to enhance clinical safety and promote professional communication, problem solving and crisis management.

Results

Nineteen participants from both hospitals attended the training. Fourteen of 19 participants completed a post training, open ended questionnaire for a 74% response rate. Fifty-seven percent of participants were able to demonstrate and provide examples of the concepts of mentorship and supervision 4 and 11 months’ post training. Participants indicated that while confidence in skills was not lacking, barriers to quality care lay mostly in understaffing. Implementation also offered multiple insights into contextual factors affecting sustainable program implementation.

Conclusions

Three recommendations from this training include: 1) A pre-program assessment should be conducted to ascertain contextual relevance to curriculum development; 2) flexibility and creativity in teaching methods are essential to engage students; and 3) access to participants a priori to program implementation may facilitate a more tailored approach and lead to greater participant engagement.

     

Societal and individual drivers of fertility desires and intentions among people living with HIV: a cross sectional study of HIV clinic attendees in Soweto,South Africa

BackgroundHigh proportion of people living with HIV (PLHIV) who are in the prime of their reproductive years desire to have children. There are limited studies that explore the range of fertility intentions for PLHIV. This study investigated the fertility desires and intentions of PLHIV and the associated factors.MethodsThis was a cross-sectional study of 442 PLHIV receiving antiretroviral treatment (ART) in health facilities in Soweto, an urban township that is situated in the City of Johannesburg in South Africa. STATA version 13 was used to analyze the data.ResultsThe participants'' mean age was 36.3 years, 70% were females, 79.6% had at least one biological child, and 36% had 3+ children. Almost half (47%) expressed the desire for children, saying that this was because they had no biological children, or their partners wanted children, or they wanted children of a particular sex, or were feeling healthy after taking ART. An increased fertility desire was associated with absence of biological children (AOR = 5.06, 95% CI: 2.11–12.1) and with being married (AOR = 2.63, 95% CI: 1.31–5.27). A decreased fertility desire was associated with being aged 36+ (AOR = 2.63, 95% CI: 1.31–5.27), having primary education (AOR = 0.11, 95% CI: 0.01–1.30) and having ≥4 years of ART duration (AOR = 0.45, 95% CI: 0.24–0.81).ConclusionIndividual factors played a significant role in shaping the fertility desires of PLHIV in this setting. The high desire for children underscore the need to integrate reproductive health services in HIV and AIDS care and treatment services and develop safer conception programmes to help PLHIV to conceive and have children safely.     

Chronic inflammatory cells and damaged limbal cells in pterygium

Background

Chronic inflammation in pterygium occurrence has not been explained. Whether damaged limbal basal epithelial cells are associated with pterygium occurrence in black Africans is not clear.

Objective

To explain chronic inflammation in pterygium, and to clarify whether damaged limbal basal epithelial cells were associated with pterygium occurrence in black Africans.

Methods

Chronic inflammatory changes and damaged limbal basal epithelial cells were assessed in 59 samples.

Results

Chronic inflammatory cells were present in 59 pterygia. Inflammatory cell count in 5 (27.8%) of 18 small pterygia was >200 (high) while in 22 (53.7%) of 41 large growths was <200 (low); p = 0.25. The proportion of pterygia with high counts tended to increase with pterygium extent. Twenty (33.9%) of 59 pterygia recurred after surgery. Ten (50%) of 20 samples had high cell counts and 10 (50%), low counts; p = 0.40.P53 expression was detected in 11 (18.6%) of 59 pterygium samples and 5 (71.4%) of 7 controls; p = 0.007. MMP 1 staining was present in 14 (23.7%) of 59 sections and 5 (71.4%) of 7 controls; p = 0.02. MMP2 in 16 (27.1%) cases and 5 (71.4%) controls; p = 0.03. MMP3 was overexpressed in 16 (27.1%) of 59 cases and 5 (71.4%) controls; p = 0.03.

Conclusions

Mild chronic inflammation has a tendency to be more frequent than severe inflammation in pterygia. It is clear that damaged limbal basal epithelial cells are unlikely to be related to pterygium occurrence.     

Bank accounts for public primary health care facilities: Reflections on implementation from three districts in Tanzania

Health care financing reforms are gaining popularity in a number of African countries to increase financial resources and promote financial autonomy, particularly at peripheral health care facilities. The paper explores the establishment of facility bank accounts at public primary facilities in Tanzania, with the intention of informing other countries embarking on such reform of the lessons learned from its implementation process. A case study approach was used, in which three district councils were purposively sampled. A total of 34 focus group discussions and 14 in‐depth interviews were conducted. Thematic content analysis was used during analysis. The study revealed that the main use of bank account revenue was for the purchase of drugs, medical supplies, and minor facility needs. To ensure accountability for funds, health care facilities had to submit monthly reports of expenditures incurred. District managers also undertook quality control of facility infrastructure, which had been renovated using facility resources and purchases of facility needs. Facility autonomy in the use of revenue retained in their accounts would improve the availability of drugs and service delivery. The experienced process of opening facility bank accounts, managing, and using the funds highlights the need to strengthen the capacity of staff and health‐governing committees.     

Global Equity Gauge Alliance

The lack of attention to equity in health, health care and determinants of health is a burden to the attainment of good health in many countries. With this underlying problem as a basis, a series of meetings took place between 1999 and 2000, culminating in the creation the Global Equity Gauge Alliance (GEGA). G EGA is an international network of groups in developing countries, mainly Asia, Africa and Latin America, which develop projects designed to confront and mitigate inequities in health, know as Equity Gauges. Equity Gauges aim to contribute towards the sustained decline in inequities in both the broad sociopolitical determinants of health, as well as inequities in the health system. Their approach is based on three broad spheres of action, known as "pillars": 1) measurement and monitoring, 2) advocacy, and 3) community empowerment. Through a series of examples from local or national level gauges, this paper showcases their work promoting the interaction between research and evidence-based policy formulation and implementation, and the interaction between the community and policy makers.     

Revealing the full extent of households' experiences of HIV and AIDS in rural South Africa

Households experience HIV and AIDS in a complex and changing set of environments. These include health and welfare treatment and support services, HIV-related stigma and discrimination, and individual and household social and economic circumstances. This paper documents the experiences of 12 households directly affected by HIV and AIDS in rural KwaZulu Natal, South Africa, between 2002 and 2004. The households were observed during repeated visits over a period of more than a year by ethnographically trained researchers. Field notes were analysed using thematic content analysis to identify themes and sub-themes. This paper focuses on three dimensions of household experience of HIV and AIDS that have received little attention in HIV and AIDS impact studies. First, that experience of HIV and AIDS is cumulative. In an area where population surveys report HIV prevalence rates of over 20% in adults, many households face multiple episodes of HIV-related illness and AIDS deaths. We describe how these challenges affect perceptions and responses within and outside households. Second, while over 50% of all adult deaths are due to AIDS, households continue to face other causes of illness and death. We show how these other causes compound the impact of AIDS, particularly where the deceased was the main income earner and/or primary carer for young children. Third, HIV-related illness and AIDS deaths of household members are only part of the households' cumulative experience of HIV and AIDS. Illness and death of non-household members, for example, former partners who are parents of children within the households or relatives who provide financial support, also impact negatively on households. We also discuss how measuring multiple episodes of illness and deaths can be recorded in household surveys in order to improve quantitative assessments of the impact of HIV and AIDS.     

Young patient's age determines pterygium recurrence after surgery

Background

It is not clear whether demographic or pterygium characteristics or limbal stem cell deficiency determine pterygium recurrence after surgery.

Purpose

To determine whether the demographic, pterygium characteristics, or limbal stem cell deficiency determine pterygium recurrence after excision.

Methods

Of 190 patients operated and followed-up for 6 months, 101 and 89 underwent free conjunctival autotransplant (CAT) or limbal conjunctival autotransplant (LCAT) respectively. The age, gender, occupation, grade of pterygium extent and degree of fleshiness, and laterality were compared between recurrent and no recurrent pterygia. Multivariate analysis was performed to determine the predictors of pterygium recurrence. Recurrence rates after surgery were compared between CAT and LCAT.

Results

The age range of the 190 patients was 22–65 years, mean ±SD 46.4 ±10.8 years. Pterygium recurred in 52 (27.4%). Thirty-nine (75%) of 52 patients with pterygia that recurred were aged <50 years (young) vs. 72 (52%) of 138 young patients with no recurrence; odds ratio (OR) = 1.54; 95% confidence interval (95% CI) = 0.70–3.36; p = 0.28. Thirty-one (60%) of 52 participants with post-surgical recurrent pterygia had large pre-operative pterygium (grade ≥3) vs. 130 (94%) of 138 patients with large pterygia that did not recur; OR = 0.11; 95% CI = 0.04–0.28; p <0.001. Of 101 patients undergoing CAT, 29 (28.7%) experienced recurrence vs. 23 (25.8%) of 89 undergoing LCAT; p = 0.66.

Conclusions

Young age seems to be associated with pterygium recurrence after excision followed by conjunctival graft. Large pterygia were protective.