Publications by authors named "David H Peters"

127 Publications

The effectiveness of supervision strategies to improve health care provider practices in low- and middle-income countries: secondary analysis of a systematic review.

Hum Resour Health 2022 Jan 6;20(1). Epub 2022 Jan 6.

Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, USA.

Background: Although supervision is a ubiquitous approach to support health programs and improve health care provider (HCP) performance in low- and middle-income countries (LMICs), quantitative evidence of its effects is unclear. The objectives of this study are to describe the effect of supervision strategies on HCP practices in LMICs and to identify attributes associated with greater effectiveness of routine supervision.

Methods: We performed a secondary analysis of data on HCP practice outcomes (e.g., percentage of patients correctly treated) from a systematic review on improving HCP performance. The review included controlled trials and interrupted time series studies. We described distributions of effect sizes (defined as percentage-point [%-point] changes) for each supervision strategy. To identify attributes associated with supervision effectiveness, we performed random-effects linear regression modeling and examined studies that directly compared different approaches of routine supervision.

Results: We analyzed data from 81 studies from 36 countries. For professional HCPs, such as nurses and physicians, primarily working at health facilities, routine supervision (median improvement when compared to controls: 10.7%-points; IQR: 9.9, 27.9) had similar effects on HCP practices as audit with feedback (median improvement: 10.1%-points; IQR: 6.2, 23.7). Two attributes were associated with greater mean effectiveness of routine supervision (p < 0.10): supervisors received supervision (by 8.8-11.5%-points), and supervisors participated in problem-solving with HCPs (by 14.2-20.8%-points). Training for supervisors and use of a checklist during supervision visits were not associated with effectiveness. The effects of supervision frequency (i.e., number of visits per year) and dose (i.e., the number of supervision visits during a study) were unclear. For lay HCPs, the effect of routine supervision was difficult to characterize because few studies existed, and effectiveness in those studies varied considerably. Evidence quality for all findings was low primarily because many studies had a high risk of bias.

Conclusions: Although evidence is limited, to promote more effective supervision, our study supports supervising supervisors and having supervisors engage in problem-solving with HCPs. Supervision's integral role in health systems in LMICs justifies a more deliberate research agenda to identify how to deliver supervision to optimize its effect on HCP practices.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12960-021-00683-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8734232PMC
January 2022

A Special Issue Honoring the Legacy of Adam Wagstaff.

Health Syst Reform 2021 07;7(2):e1968326

Human Development Practice Group, World Bank, Washington, DC, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1080/23288604.2021.1968326DOI Listing
July 2021

An Empirical Examination of the Inequality of Forgone Care in India.

Health Syst Reform 2021 07;7(2):e1894761

Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.

Understanding how well a health system is meeting the needs of the population is critical to achieving the policy aspirations of universal health coverage. This study focuses on assessing the inequity of forgone care for priority maternal and child health services across India. We utilize data from the 4th round of the Indian National Family Health Survey (NFHS-4) to examine inequality of forgone care. Our outcomes include forgone institutional delivery, antenatal care, medical care for a child with fever or cough, and medical care for a child with diarrhea. Wagstaff's standardized concentration indices (CIs) are computed at the national level, over urban and rural sub-populations, and by state. Regression decomposition is performed to determine the influence of specific drivers on overall inequality. There was significant variation in the national-level prevalence and CIs for forgone antenatal care (17.8%, CI: -0.423), forgone medical care for a child with fever or cough (32.4%, CI: -0.199), forgone medical care for a child with diarrhea (33.8%, CI: -0.172), and forgone institutional delivery (24.5%, CI: -0.436). For all outcomes, forgone care is disproportionately concentrated among the poor, particularly in rural areas. There is also significant heterogeneity in state-level inequalities. Decomposition analyses show that socioeconomic status, maternal education, rural status, and state-level per capita health spending are the leading drivers of observed inequalities in forgone care. Results suggest attending to both the operation and financing of India's health care system as well as the social determinants that make poor women more likely to forgo maternal health care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1080/23288604.2021.1894761DOI Listing
July 2021

Examining policy intentions and actual implementation practices: How organizational factors influence health management information systems in Uttar Pradesh, India.

Soc Sci Med 2021 10 19;286:114291. Epub 2021 Aug 19.

Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States.

This study investigates the implementation of a recent health management information systems (HMIS) policy reform in Uttar Pradesh, India, which aims to improve the quality and use of HMIS data in decision-making. Through in-depth interviews, meeting observations and a policy document review, this study sought to capture the experiences of district-level staff (street-level bureaucrats) who were responsible for HMIS policy implementation. Findings revealed that issues of weak HMIS implementation were partly due to human resources shortages both in number and technical skill. Delays in recruitment and the presence of inactive staff overburdened existing staff and weakened the implementation of HMIS activities at the block- and district-levels. District staff also explained how inadequate computer literacy and limited technical understanding further contributed to low HMIS data quality. The organizational culture was even more constraining: working within a very rigid and hierarchical organization was challenging for district data staff, who were expected to manage day-to-day HMIS activities, but lacked the discretion and authority to do so effectively. Consequently, they had to escalate minor issues to district leadership for action and were expected to follow their supervisors' directives- even if they contradicted HMIS policy guidelines. High performance pressures associated with achieving top district rankings deviated focus away from HMIS data quality issues. Many district-level respondents described their superiors' "fixation" with becoming a top-ranking district often resulted in disregard for the quality of data informing district rankings. Furthermore, the review of district rankings only partially encouraged district-level leadership to investigate reasons for low-performing indicators. Instead, low district rankings often resulted in punitive action. The study recommends the importance of incorporating the perspectives of district staff, and recognizing their discretion, and authority when designing policy implementation processes, and finally concludes with potential strategies for strengthening the current HMIS policy reform.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.socscimed.2021.114291DOI Listing
October 2021

Time to reconceptualise health systems.

Lancet 2021 06 24;397(10290):2145. Epub 2021 May 24.

Alliance for Health Policy and Systems Research, WHO, Geneva 1211, Switzerland.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/S0140-6736(21)01019-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8143729PMC
June 2021

How does the effectiveness of strategies to improve healthcare provider practices in low-income and middle-income countries change after implementation? Secondary analysis of a systematic review.

BMJ Qual Saf 2022 Feb 18;31(2):123-133. Epub 2021 May 18.

Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA.

Background: A recent systematic review evaluated the effectiveness of strategies to improve healthcare provider (HCP) performance in low-income and middle-income countries. The review identified strategies with varying effects, including in-service training, supervision and group problem-solving. However, whether their effectiveness changed over time remained unclear. In particular, understanding whether effects decay over time is crucial to improve sustainability.

Methods: We conducted a secondary analysis of data from the aforementioned review to explore associations between time and effectiveness. We calculated effect sizes (defined as percentage-point (%-point) changes) for HCP practice outcomes (eg, percentage of patients correctly treated) at each follow-up time point after the strategy was implemented. We estimated the association between time and effectiveness using random-intercept linear regression models with time-specific effect sizes clustered within studies and adjusted for baseline performance.

Results: The primary analysis included 37 studies, and a sensitivity analysis included 77 additional studies. For training, every additional month of follow-up was associated with a 0.19 %-point decrease in effectiveness (95% CI: -0.36 to -0.03). For training combined with supervision, every additional month was associated with a 0.40 %-point decrease in effectiveness (95% CI: -0.68 to -0.12). Time trend results for supervision were inconclusive. For group problem-solving alone, time was positively associated with effectiveness, with a 0.50 %-point increase in effect per month (95% CI: 0.37 to 0.64). Group problem-solving combined with training was associated with large improvements, and its effect was not associated with time.

Conclusions: Time trends in the effectiveness of different strategies to improve HCP practices vary among strategies. Programmes relying solely on in-service training might need periodical refresher training or, better still, consider combining training with group problem-solving. Although more high-quality research is needed, these results, which are important for decision-makers as they choose which strategies to use, underscore the utility of studies with multiple post-implementation measurements so sustainability of the impact on HCP practices can be assessed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/bmjqs-2020-011717DOI Listing
February 2022

Impact of Public Health and Social Measures on the COVID-19 Pandemic in the United States and Other Countries: Descriptive Analysis.

JMIR Public Health Surveill 2021 06 2;7(6):e27917. Epub 2021 Jun 2.

Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States.

Background: The United States of America has the highest global number of COVID-19 cases and deaths, which may be due in part to delays and inconsistencies in implementing public health and social measures (PHSMs).

Objective: In this descriptive analysis, we analyzed the epidemiological evidence for the impact of PHSMs on COVID-19 transmission in the United States and compared these data to those for 10 other countries of varying income levels, population sizes, and geographies.

Methods: We compared PHSM implementation timing and stringency against COVID-19 daily case counts in the United States and against those in Canada, China, Ethiopia, Japan, Kazakhstan, New Zealand, Singapore, South Korea, Vietnam, and Zimbabwe from January 1 to November 25, 2020. We descriptively analyzed the impact of border closures, contact tracing, household confinement, mandated face masks, quarantine and isolation, school closures, limited gatherings, and states of emergency on COVID-19 case counts. We also compared the relationship between global socioeconomic indicators and national pandemic trajectories across the 11 countries. PHSMs and case count data were derived from various surveillance systems, including the Health Intervention Tracking for COVID-19 database, the World Health Organization PHSM database, and the European Centre for Disease Prevention and Control.

Results: Implementing a specific package of 4 PHSMs (quarantine and isolation, school closures, household confinement, and the limiting of social gatherings) early and stringently was observed to coincide with lower case counts and transmission durations in Vietnam, Zimbabwe, New Zealand, South Korea, Ethiopia, and Kazakhstan. In contrast, the United States implemented few PHSMs stringently or early and did not use this successful package. Across the 11 countries, national income positively correlated (r=0.624) with cumulative COVID-19 incidence.

Conclusions: Our findings suggest that early implementation, consistent execution, adequate duration, and high adherence to PHSMs represent key factors of reducing the spread of COVID-19. Although national income may be related to COVID-19 progression, a country's wealth appears to be less important in controlling the pandemic and more important in taking rapid, centralized, and consistent public health action.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2196/27917DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8174555PMC
June 2021

Assessing Barriers to Effective Coverage of Health Services for Adolescents in Low- and Middle-Income Countries: A Scoping Review.

J Adolesc Health 2021 10 9;69(4):541-548. Epub 2021 Mar 9.

Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland.

Purpose: Understanding barriers to health services, as experienced by adolescents, is important to expand effective and equitable coverage; however, there is limited discussion on methods for conducting barrier assessments and translating findings into action.

Methods: We conducted a scoping review of literature published between 2005 and 2019 on barriers to health services for adolescents in low- and middle-income countries. The review was guided by a framework that conceptualized barriers across multiple dimensions of access (availability, geographic accessibility, affordability, and acceptability), utilization, and effective coverage.

Results: We identified 339 studies that assessed barriers related to at least one dimension of the operational framework. Acceptability (93%) and availability (88%) of health services were the most frequently studied access dimensions; affordability (45%) and geographic access (32%) were studied less frequently. Less than half (40%) of the studies evaluated utilization, and none of the 339 studies assessed effective coverage. Attention to equity stratifiers (e.g., income, disability) was limited. Topics studied reflected only a subset of the major causes of adolescent death and disability.

Conclusions: Holistic, equity-oriented approaches are needed to better understand barriers across multiple dimensions that together determine whether health services are accessible, used, and effectively meet the needs of different adolescent groups.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jadohealth.2020.12.135DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8442758PMC
October 2021

Towards Core Competencies for Health Policy and Systems Research (HPSR) Training: Results From a Global Mapping and Consensus-Building Process.

Int J Health Policy Manag 2020 Dec 30. Epub 2020 Dec 30.

London School of Hygiene and Tropical Medicine, London, UK.

Background: As the field of health policy and systems research (HPSR) continues to grow, there is a recognition of the need for training in HPSR. This aspiration has translated into a multitude of teaching programmes of variable scope and quality, reflecting a lack of consensus on the skills and practices required for rigorous HPSR. The purpose of this paper is to identify an agreed set of core competencies for HPSR researchers, building on the previous work by the Health Systems Global (HSG) Thematic Working Group on Teaching & Learning.

Methods: Our methods involved an iterative approach of four phases including a literature review, key informant interviews and group discussions with HPSR educators, and webinars with pre-post surveys capturing views among the global HPSR community. The phased discussions and consensus-building contributed to the evolution of the HPSR competency domains and competencies framework.

Results: Emerging domains included understanding health systems complexity, assessing policies and programs, appraising data and evidence, ethical reasoning and practice, leading and mentoring, building partnerships, and translating and utilizing knowledge and HPSR evidence. The development of competencies and their application were often seen as a continuous process spanning evidence generation, partnering, communicating and helping to identify new critical health systems questions.

Conclusion: The HPSR competency set can be seen as a useful reference point in the teaching and practice of high-quality HPSR and can be adapted based on national priorities, the particularities of local contexts, and the needs of stakeholders (HPSR researchers and educators), as well as practitioners and policy-makers. Further research is needed in using the core competency set to design national training programmes, develop locally relevant benchmarks and assessment methods, and evaluate their use in different settings.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.34172/ijhpm.2020.258DOI Listing
December 2020

The effectiveness of training strategies to improve healthcare provider practices in low-income and middle-income countries.

BMJ Glob Health 2021 01;6(1)

Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.

Introduction: In low/middle-income countries (LMICs), training is often used to improve healthcare provider (HCP) performance. However, important questions remain about how well training works and the best ways to design training strategies. The objective of this study is to characterise the effectiveness of training strategies to improve HCP practices in LMICs and identify attributes associated with training effectiveness.

Methods: We performed a secondary analysis of data from a systematic review on improving HCP performance. The review included controlled trials and interrupted time series, and outcomes measuring HCP practices (eg, percentage of patients correctly treated). Distributions of effect sizes (defined as percentage-point (%-point) changes) were described for each training strategy. To identify effective training attributes, we examined studies that directly compared training approaches and performed random-effects linear regression modelling.

Results: We analysed data from 199 studies from 51 countries. For outcomes expressed as percentages, educational outreach visits (median effect size when compared with controls: 9.9 %-points; IQR: 4.3-20.6) tended to be somewhat more effective than in-service training (median: 7.3 %-points; IQR: 3.6-17.4), which seemed more effective than peer-to-peer training (4.0 %-points) and self-study (by 2.0-9.3 %-points). Mean effectiveness was greater (by 6.0-10.4 %-points) for training that incorporated clinical practice and training at HCPs' work site. Attributes with little or no effect were: training with computers, interactive methods or over multiple sessions; training duration; number of educational methods; distance training; trainers with pedagogical training and topic complexity. For lay HCPs, in-service training had no measurable effect. Evidence quality for all findings was low.

Conclusions: Although additional research is needed, by characterising the effectiveness of training strategies and identifying attributes of effective training, decision-makers in LMICs can improve how these strategies are selected and implemented.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/bmjgh-2020-003229DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7813291PMC
January 2021

Strengthening social accountability in ways that build inclusion, institutionalization and scale: reflections on FHS experience.

Int J Equity Health 2020 12 10;19(1):220. Epub 2020 Dec 10.

Department of International Health, Johns Hopkins Bloomberg School of Public Health, 614 N Wolfe St, Baltimore, MD, USA.

This editorial provides an introduction to the special issue on "Lessons about intervening in accountability ecosystems: implementation of community scorecards in Bangladesh and Uganda". We start by describing the rationale for this work in the two study countries. While our project, the Future Health Systems (FHS) project, had been working over the course of more than a decade to strengthen health services, particularly for low income households in rural areas, our teams increasingly recognized how difficult it would be to sustain service improvements without fundamental changes to local accountabilities. Accordingly, in the final phase of the project 2016-2018, we designed, implemented and assessed community scorecard initiatives, in both Bangladesh and Uganda, with the aim of informing the design of a scalable social accountability initiative that could fundamentally shift the dynamics of health system accountability in favor of the poor and marginalized.We describe the particular characteristics of our approach to this task. Specifically we (i) conducted a mapping of accountabilities in each of the contexts so as to understand how our actions may interact with existing accountability mechanisms (ii) developed detailed theories of change that unpacked the mechanisms through which we anticipated the community scorecards would have effect, as well as how they would be institutionalized; and (iii) monitored closely the extent of inclusion and the equity effects of the scorecards. In summarizing this approach, we articulate the contributions made by different papers in this volume.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12939-020-01341-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7731752PMC
December 2020

Identifying core competencies for practicing public health professionals: results from a Delphi exercise in Uttar Pradesh, India.

BMC Public Health 2020 Nov 17;20(1):1737. Epub 2020 Nov 17.

Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.

Background: Ensuring the current public health workforce has appropriate competencies to fulfill essential public health functions is challenging in many low- and middle-income countries. The absence of an agreed set of core competencies to provide a basis for developing and assessing knowledge, skills, abilities, and attitudes contributes to this challenge. This study aims to identify the requisite core competencies for practicing health professionals in mid-level supervisory and program management roles to effectively perform their public health responsibilities in the resource-poor setting of Uttar Pradesh (UP), India.

Methods: We used a multi-step, interactive Delphi technique to develop an agreed set of public health competencies. A narrative review of core competency frameworks and key informant interviews with human resources for health experts in India were conducted to prepare an initial list of 40 competency statements in eight domains. We then organized a day-long workshop with 22 Indian public health experts and government officials, who added to and modified the initial list. A revised list of 54 competency statements was rated on a 5-point Likert scale. Aggregate statement scores were shared with the participants, who discussed the findings. Finally, the revised list was returned to participants for an additional round of ratings. The Wilcoxon matched-pairs signed-rank test was used to identify stability between steps, and consensus was defined using the percent agreement criterion.

Results: Stability between the first and second Delphi scoring steps was reached in 46 of the 54 statements. By the end of the second Delphi scoring step, consensus was reached on 48 competency statements across eight domains: public health sciences, assessment and analysis, policy and program management, financial management and budgeting, partnerships and collaboration, social and cultural determinants, communication, and leadership.

Conclusions: This study produced a consensus set of core competencies and domains in public health that can be used to assess competencies of public health professionals and revise or develop new training programs to address desired competencies. Findings can also be used to support workforce development by informing competency-based job descriptions for recruitment and performance management in the Indian context, and potentially can be adapted for use in resource-poor settings globally.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12889-020-09711-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7670983PMC
November 2020

How does embedded implementation research work? Examining core features through qualitative case studies in Latin America and the Caribbean.

Health Policy Plan 2020 Nov;35(Supplement_2):ii98-ii111

Department of International Health, Johns Hopkins School of Public Health, 615 N Wolfe St, Baltimore, MD 21205, United States.

Innovative strategies are needed to improve the delivery of evidence-informed health interventions. Embedded implementation research (EIR) seeks to enhance the generation and use of evidence for programme improvement through four core features: (1) central involvement of programme/policy decision-makers in the research cycle; (2) collaborative research partnerships; (3) positioning research within programme processes and (4) research focused on implementation. This paper examines how these features influence evidence-to-action processes and explores how they are operationalized, their effects and supporting conditions needed. We used a qualitative, comparative case study approach, drawing on document analysis and semi-structured interviews across multiple informant groups, to examine three EIR projects in Bolivia, Colombia and the Dominican Republic. Our findings are presented according to the four core EIR features. The central involvement of decision-makers in EIR was enhanced by decision-maker authority over the programme studied, professional networks and critical reflection. Strong research-practice partnerships were facilitated by commitment, a clear and shared purpose and representation of diverse perspectives. Evidence around positioning research within programme processes was less conclusive; however, as all three cases made significant advances in research use and programme improvement, this feature of EIR may be less critical than others, depending on specific circumstances. Finally, a research focus on implementation demanded proactive engagement by decision-makers in conceptualizing the research and identifying opportunities for direct action by decision-makers. As the EIR approach is a novel approach in these low-resource settings, key supports are needed to build capacity of health sector stakeholders and create an enabling environment through system-level strategies. Key implications for such supports include: promoting EIR and creating incentives for decision-makers to engage in it, establishing structures or mechanisms to facilitate decision-maker involvement, allocating funds for EIR, and developing guidance for EIR practitioners.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/heapol/czaa126DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7646734PMC
November 2020

Influence of community scorecards on maternal and newborn health service delivery and utilization.

Int J Equity Health 2020 11 2;19(1):145. Epub 2020 Nov 2.

Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.

Introduction: The community score card (CSC) is a participatory monitoring and evaluation tool that has been employed to strengthen the mutual accountability of health system and community actors. In this paper we describe the influence of the CSC on selected maternal and newborn service delivery and utilization indicators.

Methods: This was a mixed methods study that used both quantitative and qualitative data collection methods. It was implemented in five sub-counties and one town council in Kibuku district in Uganda. Data was collected through 17 key informant interviews and 10 focus group discussions as well as CSC scoring and stakeholder meeting reports. The repeated measures ANOVA test was used to test for statistical significance. Qualitative data was analyzed manually using content analysis. The analysis about the change pathways was guided by the Wild and Harris dimensions of change framework.

Results: There was an overall improvement in the common indicators across sub-counties in the project area between the 1st and 5th round scores. Almost all the red scores had changed to green or yellow by round five except for availability of drugs and mothers attending Antenatal care (ANC) in the first trimester. There were statistically significant differences in mean scores for men escorting their wives for ante natal care (ANC) (F(4,20) = 5.45, P = 0.01), availability of midwives (F(4,16) =5.77, P < 0.01), availability of delivery beds (F(4,12) =9.00, P < 0.01) and mothers delivering from traditional birth attendants (TBAs), F(4,16) = 3.86, p = 0.02). The qualitative findings suggest that strengthening of citizens' demand, availability of resources through collaborative problem solving, increased awareness about targeted maternal health services and increased top down performance pressure contributed to positive changes as perceived by community members and their leaders.

Conclusions And Recommendations: The community score cards created opportunities for community leaders and communities to work together to identify innovative ways of dealing with the health service delivery and utilization challenges that they face. Local leaders should encourage the availability of safe spaces for dialogue between communities, health workers and leaders where performance and utilization challenges can be identified and solutions proposed and implemented jointly.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12939-020-01184-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7604954PMC
November 2020

HIT-COVID, a global database tracking public health interventions to COVID-19.

Sci Data 2020 08 27;7(1):286. Epub 2020 Aug 27.

Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.

The COVID-19 pandemic has sparked unprecedented public health and social measures (PHSM) by national and local governments, including border restrictions, school closures, mandatory facemask use and stay at home orders. Quantifying the effectiveness of these interventions in reducing disease transmission is key to rational policy making in response to the current and future pandemics. In order to estimate the effectiveness of these interventions, detailed descriptions of their timelines, scale and scope are needed. The Health Intervention Tracking for COVID-19 (HIT-COVID) is a curated and standardized global database that catalogues the implementation and relaxation of COVID-19 related PHSM. With a team of over 200 volunteer contributors, we assembled policy timelines for a range of key PHSM aimed at reducing COVID-19 risk for the national and first administrative levels (e.g. provinces and states) globally, including details such as the degree of implementation and targeted populations. We continue to maintain and adapt this database to the changing COVID-19 landscape so it can serve as a resource for researchers and policymakers alike.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1038/s41597-020-00610-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7453020PMC
August 2020

The need for COVID-19 research in low- and middle-income countries.

Glob Health Res Policy 2020 1;5:33. Epub 2020 Jul 1.

Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.

In the early months of the pandemic, most reported cases and deaths due to COVID-19 occurred in high-income countries. However, insufficient testing could have led to an underestimation of true infections in many low- and middle-income countries. As confirmed cases increase, the ultimate impact of the pandemic on individuals and communities in low- and middle-income countries is uncertain. We therefore propose research in three broad areas as urgently needed to inform responses in low- and middle-income countries: transmission patterns of SARS-CoV-2, the clinical characteristics of the disease, and the impact of pandemic prevention and response measures. Answering these questions will require a multidisciplinary approach led by local investigators and in some cases additional resources. Targeted research activities should be done to help mitigate the potential burden of COVID-19 in low- and middle-income countries without diverting the limited human resources, funding, or medical supplies from response activities.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s41256-020-00159-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7326528PMC
January 2021

Comparative Case Analysis of the Role of Community Health Workers in Rural and Low-Income Populations of West Virginia and the United States.

J Ambul Care Manage 2020 Jul/Sep;43(3):205-220

Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.

The rural United States, including West Virginia, has decades of experience engaging communities and utilizing community health workers (CHWs). This study aims to inform policy and planning by comparing how 2 county-level CHW programs engage with communities. The analysis is based on in-depth interviews with 19 community representatives and 20 health workers and archival documents and published literature reviews. Results highlight the local contextual determinants for community engagement with CHW programs. Making CHW policies inclusive and adaptable to local realities will enable more community benefits. Making the value of CHW programs for communities explicit should guide resource allocation and policies.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/JAC.0000000000000335DOI Listing
July 2021

Prevention and control of non-communicable diseases in the COVID-19 response.

Lancet 2020 05 10;395(10238):1678-1680. Epub 2020 May 10.

WHO European Office for the Prevention and Control of Noncommunicable Diseases, Moscow 125009, Russia.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/S0140-6736(20)31067-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7211494PMC
May 2020

Financing Common Goods for Health: Core Government Functions in Health Emergency and Disaster Risk Management.

Health Syst Reform 2019 29;5(4):307-321. Epub 2019 Oct 29.

National Public Health Institute of Liberia, Monrovia, Republic of Liberia.

In the absence of good data on the costs and comparative benefits from investing in health emergency and disaster risk management (EDRM), governments have been reluctant to invest adequately in systems to reduce the risks and consequences of emergencies and disasters. Yet they spend heavily on their response. We describe a set of key functional areas for investment and action in health EDRM, and calculate the costs needed to establish and operate basic health EDRM services in low- and middle-income countries, focusing on management of epidemics and disasters from natural hazards.We find that health EDRM costs are affordable for most governments. They range from an additional 4.33 USD capital and 4.16 USD annual recurrent costs per capita in low-income countries to 1.35 USD capital to 1.41 USD recurrent costs in upper middle-income countries. These costs pale in comparison to the costs of not acting-the direct and indirect costs of epidemics and other emergencies from natural hazards are more than 20-fold higher.We also examine options for the institutional arrangements needed to design and implement health EDRM. We discuss the need for creating adaptive institutions, strengthening capacities of countries, communities and health systems for managing risks of emergencies, using "all-of-society" and "all-of-state institutions" approaches, and applying lessons about rules and regulations, behavioral norms, and organizational structures to better implement health EDRM. The economic and social value, and the feasibility of institutional options for implementing health EDRM systems should compel governments to invest in these common goods for health that strengthen national health security.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1080/23288604.2019.1660104DOI Listing
July 2020

"Because Even the Person Living With HIV/AIDS Might Need to Make Babies" - Perspectives on the Drivers of Feasibility and Acceptability of an Integrated Community Health Worker Model in Iringa, Tanzania.

Int J Health Policy Manag 2019 09 1;8(9):538-549. Epub 2019 Sep 1.

School of Public Health, University of the Western Cape, Cape Town, South Africa.

Background: Countries with health workforce shortages are increasingly turning to multipurpose community health workers (CHWs) to extend integrated services to the community-level. However, there may be tradeoffs with the number of tasks a CHW can effectively perform before quality and/or productivity decline. This qualitative study was conducted within an existing program in Iringa, Tanzania where HIV-focused CHWs working as volunteers received additional training on maternal, newborn, and child health (MNCH) promotion, thereby establishing a dual role CHW model.

Methods: To evaluate the feasibility and acceptability of the combined HIV/MNCH CHW model, qualitative in-depth interviews (IDIs) with 36 CHWs, 21 supervisors, and 10 program managers were conducted following integration of HIV and MNCH responsibilities (n=67). Thematic analysis explored perspectives on task planning, prioritization and integration, workload, and the feasibility and acceptability of the dual role model. Interview data and field observations were also used to describe implementation differences between HIV and MNCH roles as a basis for further contextualizing the qualitative findings.

Results: Perspectives from a diverse set of stakeholders suggested provision of both HIV and MNCH health promotion by CHWs was feasible. Most CHWs attempted to balance HIV/MNCH responsibilities, although some prioritized MNCH tasks. An increased workload from MNCH did not appear to interfere with HIV responsibilities but drew time away from other income-generating activities on which volunteer CHWs rely. Satisfaction with the dual role model hinged on increased community respect, gaining new knowledge/skills, and improving community health, while the remuneration-level caused dissatisfaction, a complaint that could challenge sustainability. Conclusions: Despite extensive literature on integration, little research at the community level exists. This study demonstrated CHWs can feasibly balance HIV and MNCH roles, but not without some challenges related to the heavier workload. Further research is necessary to determine the quality of health promotion in both HIV and MNCH domains, and whether the dual role model can be maintained over time among these volunteers.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.15171/ijhpm.2019.38DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6815988PMC
September 2019

A Scoping Review of Investment Cases for Vaccines and Immunization Programs.

Value Health 2019 08 10;22(8):942-952. Epub 2019 Jun 10.

Initiative for Vaccine Research, Department of Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland. Electronic address:

Background: Many investment cases have recently been published intending to show the value of new health investments, but without consistent methodological approaches.

Objectives: To conduct a scoping review of existing investment cases (using vaccines and immunization programs as an example), identify common characteristics that define these investment cases, and examine their role within the broader context of the vaccine development and introduction.

Methods: A systematic search was conducted from January 1980 to November 2017 to identify investment cases in the area of vaccines and immunization programs from gray literature and electronic bibliographic databases. Investment case outcomes, objectives, key variables, target audiences, and funding sources were extracted and analyzed according to their reporting frequency.

Results: We found 24 investment cases, and most of them aim to provide information for decisions (12 cases) or advocate for a specific agenda (9 cases). Outcomes presented fell into 4 broad categories-burden of disease, cost of investment, impact of investment, and other considerations for implementation. Number of deaths averted (70%), incremental cost-effectiveness ratios (67%), and reduction in health and socioeconomic inequalities (54%) were the most frequently reported outcome measures for impact of investment. Health system capacity (79%) and vaccine financing landscape (75%) were the most common considerations for implementation. A sizable proportion (41.4%) of investment cases did not reveal their funding sources.

Conclusions: This review describes information that is critical to decision making about resource mobilization and allocation concerning vaccines. Global efforts to harmonize investment cases more broadly will increase transparency and comparability.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jval.2019.04.002DOI Listing
August 2019

Integrating Community Health Worker Roles to Improve Facility Delivery Utilization in Tanzania: Evidence from an Interrupted Time Series Analysis.

Matern Child Health J 2019 Oct;23(10):1327-1338

Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.

Objectives: Despite renewed interest in expansion of multi-tasked community health workers (CHWs) there is limited research on HIV and maternal health integration at the community-level. This study assessed the impact of integrating CHW roles for HIV and maternal health promotion on facility delivery utilization in rural Tanzania.

Methods: A 36-month time series data set (2014-2016) of reported facility deliveries from 68 health facilities in two districts of Tanzania was constructed. Interrupted time series analyses evaluated population-averaged longitudinal trends in facility delivery at intervention and comparison facilities. Analyses were stratified by district, controlling for secular trends, seasonality, and type of facility.

Results: There was no significant change from baseline in the average number of facility deliveries observed at intervention health centers/dispensaries relative to comparison sites. However, there was a significant 16% increase (p < 0.001) in average monthly deliveries in hospitals, from an average of 202-234 in Iringa Rural and from 167 to 194 in Kilolo. While total facility deliveries were relatively stable over time at the district-level, during intervention the relative change in the proportion of hospital deliveries out of total facility deliveries increased by 17.2% in Iringa Rural (p < 0.001) and 14.7% in Kilolo (p < 0.001).

Conclusions For Practice: Results suggest community-delivered outreach by dual role CHWs was successful at mobilizing pregnant women to deliver at facilities and may be effective at reaching previously under-served pregnant women. More research is necessary to understand the effect of dual role CHWs on patterns of service utilization, including decisions to use referral level facilities for obstetric care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10995-019-02783-8DOI Listing
October 2019

A systematic review of the effectiveness of strategies to improve health care provider performance in low- and middle-income countries: Methods and descriptive results.

PLoS One 2019 31;14(5):e0217617. Epub 2019 May 31.

Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.

Background: Health care provider (HCP) performance in low- and middle-income countries (LMICs) is often inadequate. The Health Care Provider Performance Review (HCPPR) is a comprehensive systematic review of the effectiveness and cost of strategies to improve HCP performance in LMICs. We present the HCPPR's methods, describe methodological and contextual attributes of included studies, and examine time trends of study attributes.

Methods: The HCPPR includes studies from LMICs that quantitatively evaluated any strategy to improve HCP performance for any health condition, with no language restrictions. Eligible study designs were controlled trials and interrupted time series. In 2006, we searched 15 databases for published studies; in 2008 and 2010, we completed searches of 30 document inventories for unpublished studies. Data from eligible reports were double-abstracted and entered into a database, which is publicly available. The primary outcome measure was the strategy's effect size. We assessed time trends with logistic, Poisson, and negative binomial regression modeling. We were unable to register with PROSPERO (International Prospective Register of Systematic Reviews) because the protocol was developed prior to the PROSPERO launch.

Results: We screened 105,299 citations and included 824 reports from 499 studies of 161 intervention strategies. Most strategies had multiple components and were tested by only one study each. Studies were from 79 countries and had diverse methodologies, geographic settings, HCP types, work environments, and health conditions. Training, supervision, and patient and community supports were the most commonly evaluated strategy components. Only 33.6% of studies had a low or moderate risk of bias. From 1958-2003, the number of studies per year and study quality increased significantly over time, as did the proportion of studies from low-income countries. Only 36.3% of studies reported information on strategy cost or cost-effectiveness.

Conclusions: Studies have reported on the efficacy of many strategies to improve HCP performance in LMICs. However, most studies have important methodological limitations. The HCPPR is a publicly accessible resource for decision-makers, researchers, and others interested in improving HCP performance.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0217617PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6544255PMC
January 2020

Asking the right question: implementation research to accelerate national non-communicable disease responses.

BMJ 2019 May 20;365:l1868. Epub 2019 May 20.

Johns Hopkins University School of Nursing, Secretariat, World Health Organization Collaborating Centres of Nursing and Midwifery, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/bmj.l1868DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6526393PMC
May 2019

How is implementation research applied to advance health in low-income and middle-income countries?

BMJ Glob Health 2019 7;4(2):e001257. Epub 2019 Mar 7.

Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.

This paper examines the characteristics of implementation research (IR) efforts in low-income and middle-income countries (LMICs) by describing how key IR principles and concepts have been used in published health research in LMICs between 1998 and 2016, with focus on how to better apply these principles and concepts to support large-scale impact of health interventions in LMICs. There is a stark discrepancy between principles of IR and what has been published. Most IR studies have been conducted under conditions where the researchers have considerable influence over implementation and with extra resources, rather than in 'real world' conditions. IR researchers tend to focus on research questions that test a proof of concept, such as whether a new intervention is feasible or can improve implementation. They also tend to use traditional fixed research designs, yet the usual conditions for managing programmes demand continuous learning and change. More IR in LMICs should be conducted under usual management conditions, employ pragmatic research paradigm and address critical implementation issues such as scale-up and sustainability of evidence-informed interventions. This paper describes some positive examples that address these concerns and identifies how better reporting of IR studies in LMICs would include more complete descriptions of strategies, contexts, concepts, methods and outcomes of IR activities. This will help practitioners, policy-makers and other researchers to better learn how to implement large-scale change in their own settings.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/bmjgh-2018-001257DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6441291PMC
March 2019

Can volunteer community health workers manage multiple roles? An interrupted time-series analysis of combined HIV and maternal and child health promotion in Iringa, Tanzania.

Health Policy Plan 2018 Dec;33(10):1096-1106

Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, USA.

Community health workers (CHWs) play a critical role in health promotion, but their workload is often oriented around a single disease. Renewed interest in expansion of multipurpose CHWs to cover an integrated package of services must contend with the debate over how effectively CHWs can perform an increased range of tasks. In this study, we examine whether an existing cadre of HIV-focused paid volunteer CHWs in Iringa, Tanzania, can take on new maternal, newborn and child health (MNCH) promotion tasks without adversely affecting their HIV role. HIV household visits conducted per month were extracted from CHW summary forms covering up to 14 months pre-intervention and 12 months of intervention data. A comparative interrupted time series using a generalized estimating equation assessed population-averaged longitudinal trends in monthly HIV visit count in the intervention ('dual-role' CHWs) vs comparison group ('single-role' CHWs). Analyses were stratified by district, accounting for secular trends, seasonality and covariates. The time series consisted of 4022 observations for HIV visit count from 187 CHWs (41% dual role). Prior to MNCH training, dual-role CHWs averaged 25-30% more HIV visits per month compared with single-role CHWs, with no other significant pre-intervention differences between groups. CHWs began conducting MNCH visits shortly after receiving training, but in the initial month of intervention, there was a 6-9% drop in the mean number of HIV visits per month among dual-role CHWs. Otherwise, there was no significant difference between single- and dual-role CHWs in the trajectories of monthly HIV visits before and after adding MNCH tasks. Dual-role CHWs appeared able to maintain their HIV client workload after adding MNCH tasks to their routines, albeit with an initial slight decline in HIV workload. This dual-role CHW model suggests potential spare capacity in vertically oriented programmes, with productivity gains possible through integration.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/heapol/czy104DOI Listing
December 2018

Implementation research: new imperatives and opportunities in global health.

Lancet 2018 11 9;392(10160):2214-2228. Epub 2018 Oct 9.

Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.

Implementation research is important in global health because it addresses the challenges of the know-do gap in real-world settings and the practicalities of achieving national and global health goals. Implementation research is an integrated concept that links research and practice to accelerate the development and delivery of public health approaches. Implementation research involves the creation and application of knowledge to improve the implementation of health policies, programmes, and practices. This type of research uses multiple disciplines and methods and emphasises partnerships between community members, implementers, researchers, and policy makers. Implementation research focuses on practical approaches to improve implementation and to enhance equity, efficiency, scale-up, and sustainability, and ultimately to improve people's health. There is growing interest in the principles of implementation research and a range of perspectives on its purposes and appropriate methods. However, limited efforts have been made to systematically document and review learning from the practice of implementation research across different countries and technical areas. Drawing on an expert review process, this Health Policy paper presents purposively selected case studies to illustrate the essential characteristics of implementation research and its application in low-income and middle-income countries. The case studies are organised into four categories related to the purposes of using implementation research, including improving people's health, informing policy design and implementation, strengthening health service delivery, and empowering communities and beneficiaries. Each of the case studies addresses implementation problems, involves partnerships to co-create solutions, uses tacit knowledge and research, and is based on a shared commitment towards improving health outcomes. The case studies reveal the complex adaptive nature of health systems, emphasise the importance of understanding context, and highlight the role of multidisciplinary, rigorous, and adaptive processes that allow for course correction to ensure interventions have an impact. This Health Policy paper is part of a call to action to increase the use of implementation research in global health, build the field of implementation research inclusive of research utilisation efforts, and accelerate efforts to bridge the gap between research, policy, and practice to improve health outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/S0140-6736(18)32205-0DOI Listing
November 2018

Effectiveness of strategies to improve health-care provider practices in low-income and middle-income countries: a systematic review.

Lancet Glob Health 2018 11 8;6(11):e1163-e1175. Epub 2018 Oct 8.

Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA.

Background: Inadequate health-care provider performance is a major challenge to the delivery of high-quality health care in low-income and middle-income countries (LMICs). The Health Care Provider Performance Review (HCPPR) is a comprehensive systematic review of strategies to improve health-care provider performance in LMICs.

Methods: For this systematic review we searched 52 electronic databases for published studies and 58 document inventories for unpublished studies from the 1960s to 2016. Eligible study designs were controlled trials and interrupted time series. We only included strategy-versus-control group comparisons. We present results of improving health-care provider practice outcomes expressed as percentages (eg, percentage of patients treated correctly) or as continuous measures (eg, number of medicines prescribed per patient). Effect sizes were calculated as absolute percentage-point changes. The summary measure for each comparison was the median effect size (MES) for all primary outcomes. Strategy effectiveness was described with weighted medians of MES. This study is registered with PROSPERO, number CRD42016046154.

Findings: We screened 216 477 citations and selected 670 reports from 337 studies of 118 strategies. Most strategies had multiple intervention components. For professional health-care providers (generally, facility-based health workers), the effects were near zero for only implementing a technology-based strategy (median MES 1·0 percentage points, IQR -2·8 to 9·9) or only providing printed information for health-care providers (1·4 percentage points, -4·8 to 6·2). For percentage outcomes, training or supervision alone typically had moderate effects (10·3-15·9 percentage points), whereas combining training and supervision had somewhat larger effects than use of either strategy alone (18·0-18·8 percentage points). Group problem solving alone showed large improvements in percentage outcomes (28·0-37·5 percentage points), but, when the strategy definition was broadened to include group problem solving alone or other strategy components, moderate effects were more typical (12·1 percentage points). Several multifaceted strategies had large effects, but multifaceted strategies were not always more effective than simpler ones. For lay health-care providers (generally, community health workers), the effect of training alone was small (2·4 percentage points). Strategies with larger effect sizes included community support plus health-care provider training (8·2-125·0 percentage points). Contextual and methodological heterogeneity made comparisons difficult, and most strategies had low quality evidence.

Interpretation: The impact of strategies to improve health-care provider practices varied substantially, although some approaches were more consistently effective than others. The breadth of the HCPPR makes its results valuable to decision makers for informing the selection of strategies to improve health-care provider practices in LMICs. These results also emphasise the need for researchers to use better methods to study the effectiveness of interventions.

Funding: Bill & Melinda Gates Foundation, CDC Foundation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/S2214-109X(18)30398-XDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6185992PMC
November 2018

Contact tracing performance during the Ebola epidemic in Liberia, 2014-2015.

PLoS Negl Trop Dis 2018 09 12;12(9):e0006762. Epub 2018 Sep 12.

Liberia Country Office, Action Contre la Faim, Paris, France.

Background: During the Ebola virus disease (EVD) epidemic in Liberia, contact tracing was implemented to rapidly detect new cases and prevent further transmission. We describe the scope and characteristics of contact tracing in Liberia and assess its performance during the 2014-2015 EVD epidemic.

Methodology/principal Findings: We performed a retrospective descriptive analysis of data collection forms for contact tracing conducted in six counties during June 2014-July 2015. EVD case counts from situation reports in the same counties were used to assess contact tracing coverage and sensitivity. Contacts who presented with symptoms and/or died, and monitoring was stopped, were classified as "potential cases". Positive predictive value (PPV) was defined as the proportion of traced contacts who were identified as potential cases. Bivariate and multivariate logistic regression models were used to identify characteristics among potential cases. We analyzed 25,830 contact tracing records for contacts who had monitoring initiated or were last exposed between June 4, 2014 and July 13, 2015. Contact tracing was initiated for 26.7% of total EVD cases and detected 3.6% of all new cases during this period. Eighty-eight percent of contacts completed monitoring, and 334 contacts were identified as potential cases (PPV = 1.4%). Potential cases were more likely to be detected early in the outbreak; hail from rural areas; report multiple exposures and symptoms; have household contact or direct bodily or fluid contact; and report nausea, fever, or weakness compared to contacts who completed monitoring.

Conclusions/significance: Contact tracing was a critical intervention in Liberia and represented one of the largest contact tracing efforts during an epidemic in history. While there were notable improvements in implementation over time, these data suggest there were limitations to its performance-particularly in urban districts and during peak transmission. Recommendations for improving performance include integrated surveillance, decentralized management of multidisciplinary teams, comprehensive protocols, and community-led strategies.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1371/journal.pntd.0006762DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6152989PMC
September 2018
-->