Publications by authors named "David Zakus"

30 Publications

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Covid-19 pandemic impact on maternal and child health services access in Nampula, Mozambique: a mixed methods research.

BMC Health Serv Res 2021 Aug 23;21(1):860. Epub 2021 Aug 23.

Faculty oh Health Sciences, Lúrio University, Nampula, Mozambique.

Background: The Covid-19 pandemic has so far infected more than 30 million people in the world, having major impact on global health with collateral damage. In Mozambique, a public state of emergency was declared at the end of March 2020. This has limited people's movements and reduced public services, leading to a decrease in the number of people accessing health care facilities. An implementation research project, The Alert Community for a Prepared Hospital, has been promoting access to maternal and child health care, in Natikiri, Nampula, for the last four years. Nampula has the second highest incidence of Covid-19. The purpose of this study is to assess the impact of Covid-19 pandemic Government restrictions on access to maternal and child healthcare services. We compared health centres in Nampula city with healthcare centres in our research catchment area. We wanted to see if our previous research interventions have led to a more resilient response from the community.

Methods: Mixed-methods research, descriptive, cross-sectional, retrospective, using a review of patient visit documentation. We compared maternal and child health care unit statistical indicators from March-May 2019 to the same time-period in 2020. We tested for significant changes in access to maternal and child health services, using KrushKall Wallis, One-way Anova and mean and standard deviation tests. We compared interviews with health professionals, traditional birth attendants and patients in the two areas. We gathered data from a comparable city health centre and the main city referral hospital. The Marrere health centre and Marrere General Hospital were the two Alert Community for a Prepared Hospital intervention sites.

Results: Comparing 2019 quantitative maternal health services access indicators with those from 2020, showed decreases in most important indicators: family planning visits and elective C-sections dropped 28%; first antenatal visit occurring in the first trimester dropped 26%; hospital deliveries dropped a statistically significant 4% (p = 0.046), while home deliveries rose 74%; children vaccinated down 20%.

Conclusion: Our results demonstrated the negative collateral effects of Covid-19 pandemic Government restrictions, on access to maternal and child healthcare services, and highlighted the need to improve the health information system in Mozambique.
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http://dx.doi.org/10.1186/s12913-021-06878-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8381138PMC
August 2021

Quality assessment in primary health care: Adolescent and Youth Friendly Service, a Mozambican case study.

Pan Afr Med J 2020 1;37. Epub 2020 Sep 1.

Faculty of Health Sciences, Lúrio University, Nampula, Mozambique.

Introduction: despite the Mozambican Ministry of Health's efforts to deliver family planning to all girls of childbearing age, the adolescent pregnancy rate remains high. The Adolescent and Youth Friendly Service (AYFS), integrated into overall primary health care programs throughout the country, aims to reverse this situation. Our study objective was to assess this health care service's quality in its location in Marrere Health Centre, Nampula, northern Mozambique, using clients' perspective.

Methods: we implemented a descriptive cross-sectional quantitative study sampling 124 individuals, who had recently accessed the AYFS at Marrere Health Centre. Data were collected through a questionnaire using a 5-point Likert scale in questions regarding satisfaction level (i.e. always, most times, sometimes, few times, never) and additional open answer questions to gain greater specific understanding.

Results: a total of 126 users of the AYFS were evaluated, all from the Emacua ethnic-linguistic group. 85 (67%) were adolescents (<19 years), 78.2% female. The mean age was 17.6 years. We found an average of 0.54 pregnancies per woman and 87 participants (69%) never had a pregnancy; of 39 (31%) who had been pregnant, 17 (44%) were able to report the date of the first prenatal visit, on average performed at week 16 (2nd trimester), though with 9 (53%) having performed it during the first trimester. Spontaneous and induced abortions were reported respectively in 4 and 34 cases, respectively, and none with adolescents. The "overall satisfaction" rate was more frequent in both groups, being answered by 93.8% of youth and adults (>= 19 years) and 72.0% of adolescents, a statistically significant difference between the two groups (p <0.05).

Conclusion: while most users are satisfied with the services there was, however, some sharp criticism. Health professionals' practice with the protocol varied, and there were significant deficiencies in information and communication with users. Open communication within families and information reinforcement about sexual and reproductive health and male participation in family planning were found to be in need of strengthening. Our recommendations include reinforcing health professional's training to protect adolescents and young people' sexual health, an important strategy in primary health care to achieve universal health coverage.
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http://dx.doi.org/10.11604/pamj.2020.37.1.22983DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7501751PMC
January 2021

Community of practice: an effective mechanism to strengthen capacity in climate change and health.

Can J Public Health 2020 12 24;111(6):862-868. Epub 2020 Sep 24.

Canadian Coalition for Global Health Research, 46 Cremona Crescent, Nepean, ON, K2G 1A1, Canada.

Setting: Climate change is one of the greatest threats to global health in the twenty-first century and has recently been declared a health emergency. The lack of effective dissemination of emerging evidence on climate change health risks, effects, and innovative interventions to health professionals presents one of the greatest challenges to climate action today.

Intervention: To identify and address the knowledge gaps at the intersection of health and climate change, the Canadian Coalition for Global Health Research (CCGHR) established a Working Group on Climate Change and Health (WGCCH). WGCCH is evolving organically into a community of practice (CoP) that aims to elevate knowledge brokering on climate change and health and expand to global multi-, inter-, and transdisciplinary realms.

Outcomes: To date, the WGCCH established a regular webinar series to share expert knowledge from around the world on intersections between climate change and health, developed short summaries on climate change impacts on broad health challenges, supported young professional training, and enhanced climate health research capacity and skills through collegial network development and other collaborative projects that emerged from CoP activities.

Implications: This paper proposes that WGCCH may serve as an example of an effective strategy to address the lack of opportunities for collaborative engagement and mutual learning between health researchers and practitioners, other disciplines, and the general public. Our experiences and lessons learned provide opportunities to learn from the growing pains and successes of an emerging climate change and health-focused CoP.
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http://dx.doi.org/10.17269/s41997-020-00400-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7728977PMC
December 2020

Clinical evaluation of the use of an mhealth intervention on quality of care provided by Community Health Workers in southwest Niger.

J Glob Health 2019 Jun;9(1):010812

World Vision International, Niamey, Niger.

Background: Under the World Health Organization's (WHO) integrated community case management (iCCM) Rapid Access Expansion Program (RAcE), World Vision Niger and Canada supported the Niger Ministry of Public Health to implement iCCM in four health districts in Niger in 2013. Community health workers (CHWs), known as (RCom), were deployed in their communities to diagnose and treat children under five years of age presenting with diarrhea, malaria and pneumonia and refer children with severe illness to the higher-level facilities. Two of the districts in southwest Niger piloted RCom using smartphones equipped with an application to support quality case management and provide good timely clinical data. A two-arm cluster randomized trial assessed the impact of use of the mHealth application mainly on quality of care (QoC), but also on motivation, retention and supervision.

Methods: A two-arm cluster randomized trial was conducted from March to October 2016 in Dosso and Doutchi districts. The intervention arm comprised 66 RCom equipped with a smartphone and 64 in the paper-based control arm. Trained expert clinicians observed each RCom assessing sick children presenting to them (264 in intervention group; 256 in control group), re-assessed each child on the same set of parameters, and made further observations regarding perceptions of motivation, retention, supervision, drug management and caregiver satisfaction. The primary outcome was a QoC score composed of diagnostic and treatment variables. Other factors were assessed by questionnaires.

Results: On average, the mHealth equipped RCom showed a 3.4% higher QoC score (mean difference of 0.83 points). They were more likely to ask about the main danger signs: convulsions (69.7% vs 50.4%,  < 0.001); incapacity to drink or eat (79.2% vs 59.4%,  < 0.001); vomiting (81.4% vs 69.9%,  < 0.01); and lethargy or unconsciousness (92.4% vs 84.8%,  < 0.01). Specifically, they consistently asked one more screening question. They were also significantly better at examining for swelling feet (40.2% vs 13.3%,  < 0.01) and advising caretakers on diarrhea, drug dosage and administration, and performed (though non-significantly) better when examining cough and breathing rates, referring all conditions, getting children to take prescribed treatments immediately and having caregivers understand treatment continuation. The control group was significantly better at diagnosing fast breathing, bloody diarrhea and severe acute malnutrition; and was somewhat better (non-significant) at treating fever and malaria. With treatment in general of the three diseases, there was no significant difference between the groups. On further inspection, 83% of the intervention group had a QoC score greater than 80% (25 out of 31), whereas only 67% of the control group had comparable performance. With respect to referrals, the intervention group performed better, mostly based on their better assessment of danger signs, with more correct (85% vs 29%) and fewer missed, plus a lower proportion of incorrect referrals, with the reverse being true for the controls ( = 0.012). There were no statistically significant differences in motivation, retention and supervision between the two groups, yet intervention RCom reported double the rate of no supervision in the last three months (31.8% vs 15.6%).

Conclusions: Results suggest that use of the mHealth application led to modestly improved QoC through better assessment of the sick children and better referral decisions by RCom, but not to improvement in the actual treatment of malaria, pneumonia and diarrhea. Considering mHealth's additional costs and logistics, questions around its viability remain. Further implementation could be improved by investing in RCom capacity building, building organization culture and strengthened supervision, all essential areas for improving any CHW program. In this real-world setting, in poor and remote communities in rural Niger, this study did not support the overall value of the mHealth intervention. Much was learned for any future mHealth interventions and scale-up.
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http://dx.doi.org/10.7189/jogh.09.010812DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6594719PMC
June 2019

Cardiovascular risk factors among people living with HIV in rural Kenya: a clinic-based study.

Cardiovasc J Afr 2019 Jan/Feb 23;30(1):52-56. Epub 2019 Jan 24.

School of Medicine, University of Nairobi, Nairobi, Kenya.

Objective: To determine the prevalence of cardiovascular risk factors and their association with antiretroviral therapy (ART) among HIV-infected adults in a rural sub-county hospital in Kenya.

Methods: This was a descriptive survey of patient charts characterising cardiovascular risk among adult patients (> 18 years) at Ukwala sub-county hospital between June 2013 and January 2015. Post-stratification survey weights were applied to obtain prevalence levels. Adjusted odds ratios (AOR) for each variable related to cardiovascular risk factors were calculated using logistic regression models.

Results: Overall, the prevalence of diabetes mellitus was 0.4%, 0.3% of patients had had a previous cardiovascular event (heart attack or stroke), 40.4% had pre-hypertension, while 10.4% had stage 1 and 2.9% stage 2 hypertension. Up to 14% of patients had elevated non-fasting total cholesterol levels. Factors associated with hypertension were male gender (AOR 1.59, = 0.0001), being over 40 years of age (AOR 1.78, = 0.0001) and having an increased waist circumference (OR 2.56, = 0.0014). Raised total cholesterol was more likely in those on tenofovir disoproxil fumarate (TDF) (AOR 2.2, p = 0.0042), azidothymidine (AZT) (AOR 2.5, = 0.0004) and stavudine (D4T) -containing regimens (AOR 3.13, = 0.0002).

Conclusions: An elevated prevalence of undiagnosed cardiovascular risk factors such as hypertension and raised total cholesterol levels was found among people living with HIV. There was an association between raised total cholesterol and nucleoside reverse-transcriptase inhibitor (NRTI) -based ART regimens. Our findings provide further rationale for integrating routine cardiovascular risk-factor screening into HIV-care services.
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http://dx.doi.org/10.5830/CVJA-2018-064DOI Listing
June 2019

Physician experiences and barriers to addressing the social determinants of health in the Eastern Mediterranean Region: a qualitative research study.

BMC Health Serv Res 2018 08 7;18(1):614. Epub 2018 Aug 7.

Department of Family Medicine, McGill University, Montreal, Canada.

Background: While it is increasingly recognized that social determinants influence the health of patients and populations, little is known about how doctors in the Eastern Mediterranean Region can help their patients with these issues. Our study aimed to identify common social challenges faced by patients in Eastern Mediterranean countries, to assess what doctors are already doing to address these challenges, and to identify barriers and facilitators for addressing the social causes of poor health in Eastern Mediterranean countries with shedding some light on how does this compare to a developed country like Canada.

Methods: We conducted a qualitative research study employing qualitative descriptive methodology. A purposeful sample as well as snowballing technique were used to recruit 18 physicians who were trained in Eastern Mediterranean countries but have since moved to Canada. Recruitment continued until data saturation was reached. A content analysis was carried out after transcribing the interviews.

Results: The main social challenges identified in clinical care in Eastern Mediterranean Regions include poverty, illiteracy, domestic violence, and food insecurity. Doctors attempted to help their patients by providing free medical services and free medications, establishing a donation box, and referring to social workers and support services, where available. Cultural constraints, lack of time, and unavailability of referral resources were often cited as important barriers. Our participants stated that Canada is generally better in dealing with the social challenges than their countries of origin.

Conclusions: Most study participants expressed their willingness to help patients in dealing with social challenges, and shared their experiences of tackling such issues, though there were also important barriers reported that would need to be overcome. Participants suggested that better addressing social challenges in clinical care would require educating both health care providers and patients about the importance of discussing the patient's social environment as part of the health care encounter, as well as advocating for broader policy approaches by governments to address the underlying social problems.
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http://dx.doi.org/10.1186/s12913-018-3408-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6081851PMC
August 2018

From HIV prevention to non-communicable disease health promotion efforts in sub-Saharan Africa: A Narrative Review.

AIDS 2018 07;32 Suppl 1:S63-S73

University of Nairobi, Nairobi, Kenya.

Objective: To synthesize published literature on noncommunicable disease (NCD) behavior change communication (BCC) interventions in sub-Saharan Africa (SSA) among persons living with HIV (PLHIV) and in the general population to inform efforts to adopt similar HIV and NCD BCC intervention activities.

Methods: We conducted a literature review of NCD BCC interventions and included 20 SSA-based studies. Inclusion criteria entailed describing a BCC intervention targeting any four priority NCDs (cardiovascular disease, type 2 diabetes, cervical cancer, and depression) or both HIV and any of the NCDs. The RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework was used to assess potential public health impact of these studies. We also solicited expert opinions from 10 key informants on the topic of HIV/NCD health promotion in five SSA countries.

Results: The BCC interventions reviewed targeted multiple parts of the HIV and NCD continuum at both individual and community levels. Various strategies (i.e. health education, social marketing, motivational interviewing, mobile health, and peer support) were employed. However, few studies addressed more than one dimension of the RE-AIM framework. Opinions solicited from the key informants supported the feasibility of integrating HIV and NCD BCC interventions in SSA potentially improving access, service provision and service demand, especially for marginalized and vulnerable populations.

Conclusion: Although HIV/NCD integration can improve effectiveness of preventive services at individual and community levels, potential public health impact of such approaches remain unknown as reach, adoptability, and sustainability of both integrated and nonintegrated NCD BCC approaches published to date have not been well characterized.
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http://dx.doi.org/10.1097/QAD.0000000000001879DOI Listing
July 2018

Benefits and challenges of EMR implementations in low resource settings: a state-of-the-art review.

BMC Med Inform Decis Mak 2016 09 6;16:116. Epub 2016 Sep 6.

Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Clinical Sciences Building, 8440-112 St NW 5th floor, 5-112E, T6G 2B7, Edmonton, AB, Canada.

Background: The intent of this review is to discover the types of inquiry and range of objectives and outcomes addressed in studies of the impacts of Electronic Medical Record (EMR) implementations in limited resource settings in sub-Saharan Africa.

Methods: A state-of-the-art review characterized relevant publications from bibliographic databases and grey literature repositories through systematic searching, concept-mapping, relevance and quality filter optimization, methods and outcomes categorization and key article analysis.

Results: From an initial population of 749 domain articles published before February 2015, 32 passed context and methods filters to merit full-text analysis. Relevant literature was classified by type (e.g., secondary, primary), design (e.g., case series, intervention), focus (e.g., processes, outcomes) and context (e.g., location, organization). A conceptual framework of EMR implementation determinants (systems, people, processes, products) was developed to represent current knowledge about the effects of EMRs in resource-constrained settings and to facilitate comparisons with studies in other contexts.

Discussion: This review provides an overall impression of the types and content of health informatics articles about EMR implementations in sub-Saharan Africa. Little is known about the unique effects of EMR efforts in slum settings. The available reports emphasize the complexity and impact of social considerations, outweighing product and system limitations. Summative guides and implementation toolkits were not found but could help EMR implementers.

Conclusion: The future of EMR implementation in sub-Saharan Africa is promising. This review reveals various examples and gaps in understanding how EMR implementations unfold in resource-constrained settings; and opportunities for new inquiry about how to improve deployments in those contexts.
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http://dx.doi.org/10.1186/s12911-016-0354-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5011989PMC
September 2016

Barriers and facilitators to Electronic Medical Record (EMR) use in an urban slum.

Int J Med Inform 2016 10 30;94:246-54. Epub 2016 Jul 30.

Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada.

Objective: Rapid urbanization has led to the growth of urban slums and increased healthcare burdens for vulnerable populations. Electronic Medical Records (EMRs) have the potential to improve continuity of care for slum residents, but their implementation is complicated by technical and non-technical limitations. This study sought practical insights about facilitators and barriers to EMR implementation in urban slum environments.

Method: Descriptive qualitative method was used to explore staff perceptions about a recent open-source EMR deployment in two primary care clinics in Kibera, Nairobi. Participants were interviewed using open-ended, semi-structured questions. Content analysis was used when exploring transcribed data.

Results: Three major themes - systems, software, and social considerations - emerged from content analysis, with sustainability concerns prevailing. Although participants reported many systems (e.g., power, network, Internet, hardware, interoperability) and software (e.g., data integrity, confidentiality, function) challenges, social factors (e.g., identity management, training, use incentives) appeared the most important impediments to sustainability.

Discussion: These findings are consistent with what others have reported, especially the importance of practical barriers to EMR deployments in resource-constrained settings. Other findings contribute unique insights about social determinants of EMR impact in slum settings, including the challenge of multiple-identity management and development of meaningful incentives to staff compliance.

Conclusions: This study exposes front-line experiences with opportunities and shortcomings of EMR implementations in urban slum primary care clinics. Although the promise is great, there are a number of unique system, software and social challenges that EMR advocates should address before expecting sustainable EMR use in resource-constrained settings.
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http://dx.doi.org/10.1016/j.ijmedinf.2016.07.015DOI Listing
October 2016

Paving the way for universal family planning coverage in Ethiopia: an analysis of wealth related inequality.

Int J Equity Health 2015 Sep 14;14:77. Epub 2015 Sep 14.

School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia.

Background: Family planning plays a significant role in reducing maternal and child mortality and ultimately in achieving national and international development goals. It also has an important role in reducing new pediatric HIV infections by preventing unwanted pregnancies among HIV positive women. Investing in family planning is one of the smart investments for development as population dynamics have a fundamental influence on the pillars of sustainable development, including that of a sustainable environment.

Objective: To identify and quantify wealth related differences in family planning use between poor and rich Ethiopian women based on the Demographic and Health Survey asset based wealth quintiles.

Methods: The proportion of women who used contraceptives during implementation of the 2011 and 2005 Ethiopia Demographic and Health Surveys was calculated across wealth quintiles. Data were stratified for place of residence to analyze and determine inequalities in family planning use separately for rural and urban women. Socioeconomic inequalities according to wealth were measured using the slope index of inequality and the relative index of inequality.

Result: The absolute difference of contraceptive prevalence between poorest and richest women was over 25.3 percentage points (95% CI = 18.9-31.7) in 2011. Contraceptive use was more than twice (RII: 2.6, 95% CI = 2.0 - 3.3) as prevalent among the richest compared with the poorest.

Conclusion: Despite efforts to provide contraceptives for free at all public health facilities, wealth based inequalities still prevail in Ethiopia. People at lower socioeconomic strata should be empowered more to avoid the root causes of inequality and to achieve national Health Sector Development Program Goals.
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http://dx.doi.org/10.1186/s12939-015-0214-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4568578PMC
September 2015

NRCMS capitation reform and effect evaluation in Pudong New Area of Shanghai.

Int J Health Plann Manage 2016 Jul 18;31(3):e131-57. Epub 2015 Aug 18.

Pudong New Area Health and Family Planning Commission, Shanghai, 200125, China.

The Rural Cooperative Medical Scheme (RCMS) had played an important role in guaranteeing the acquisition of basic medical healthcare of China's rural populations, being an innovative model of the medical insurance system for so many years here in China. Following the boom and bust of RCMS, the central government rebuilt the New Rural Cooperative Medical Scheme (NRCMS) in 2003 across the whole country. Shanghai, one of the developed cities in China, has developed its RCMS and NRCMS as an advanced and exemplary representative of Chinese rural health insurance. But in the past 10 years, its NRCMS has encountered such challenges as a spiral of medical expenditures and a decrease of insurance participants. Previous investigations showed that the capitation and general practitioner (GP) system had great effect on medical cost containment. Thus, the capitation reform combined with GP system reform of NRCMS, based on a system design, was implemented in Pudong New Area of Shanghai as of 1 August 2012. The aim of the current investigation was to present how the reform was designed and implemented, evaluating its effect by analyzing the data acquired from 12 months before and after the reform. This was an empirical study; we made a conceptual design of the reform to be implemented in Pudong New Area. Most data were derived from the institution-based surveys and supplemented by a questionnaire survey, qualitative interviews and policy document analysis. We found that most respondents held an optimistic attitude towards the reform. We employed a structure-process-outcome evaluation index system to evaluate the effect of the reform, finding that the growth rate of the insured population's total medical costs and NRCMS funds slowed down significantly after the reform; that the total medical expenditure of the insured rural population decreased by 3.60%; and that the total expenditure of NRCMS decreased by 3.99%. The capitation was found to help the medical staff build active cost control consciousness. Approximately 2.3% of the outpatients flowed to the primary hospitals from the secondary hospitals; and farmers' annual medical burden was relieved to a certain degree. Meanwhile, it did not affect farmers' utilization and benefits of healthcare. However, further reform still faces new challenges: The capitation reform should be well combined with the primary healthcare system to realize the "dual gatekeeper" of GPs; a variety of payment methods should be mixed on the basis of capitation to avoid possible mistakes by one single approach; and the supervision of medical institutions should be strengthened. A long-term follow-up study need to be carried out to evaluate the effects of the capitation reform so as to improve the design of the program. Copyright © 2015 John Wiley & Sons, Ltd.
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http://dx.doi.org/10.1002/hpm.2302DOI Listing
July 2016

Bridging the gap between the technological singularity and mainstream medicine: highlighting a course on technology and the future of medicine.

Glob J Health Sci 2013 Sep 9;5(6):112-25. Epub 2013 Sep 9.

University of Alberta.

The "technological singularity" is defined as that putative point in time forecasted to occur in the mid twenty-first century when machines will become smarter than humans, leading humans and machines to merge. It is hypothesized that this event will have a profound influence on medicine and population health. This work describes a new course on Technology and the Future of Medicine developed by a diverse, multi-disciplinary group of faculty members at a Canadian university. The course began as a continuous professional learning course and was later established as a recognized graduate course. We describe the philosophy of the course, the barriers encountered in course development, and some of the idiosyncratic solutions that were developed to overcome these, including the use of YouTube audience retention analytics. We hope that this report might provide a useful template for other institutions attempting to set up similar programs.
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http://dx.doi.org/10.5539/gjhs.v5n6p112DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4776857PMC
September 2013

Barriers and facilitators to care for the terminally ill: a cross-country case comparison study of Canada, England, Germany, and the United States.

Palliat Med 2014 Feb 25;28(2):111-20. Epub 2013 Jun 25.

1Institute of Health Policy, Management & Evaluation (IHPME), University of Toronto, Toronto, ON, Canada.

Background: Why do many patients not die at their preferred location?

Aim: Analyze system-level characteristics influencing the ability to implement best practices in delivering care for terminally ill adults (barriers and facilitators).

Design: Cross-country comparison study from a "most similar-most different" perspective, triangulating evidence from a scoping review of the literature, document analyses, and semi-structured key informant interviews.

Setting: Case study of Canada, England, Germany, and the United States.

Results: While similar with regard to leading causes of death, patient needs, and potential avenues to care, different models of service provision were employed in the four countries studied. Although hospice and palliative care services were generally offered with standard care along the disease continuum and in various settings, and featured common elements such as physical, psycho-social, and spiritual care, outcomes (access, utilization, etc.) varied across jurisdictions. Barriers to best practice service provision included legislative (including jurisdictional), regulatory (e.g. education and training), and financial issues as well as public knowledge and perception ("giving up hope") challenges. Advance care planning, dedicated and stable funding toward hospice and palliative care, including caregiver benefits, population aging, and standards of practice and guidelines to hospice and palliative care, were identified as facilitators.

Conclusion: Successful implementation of effective and efficient best practice approaches to care for the terminally ill, such as shared care, requires concerted action to align these system-level characteristics; many factors were identified as being essential but not sufficient. Policy implementation needs to be tailored to the respective health-care system(s), monitored, and fine-tuned.
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http://dx.doi.org/10.1177/0269216313493342DOI Listing
February 2014

Multifaceted support for a new medical school in Nepal devoted to rural health by a Canadian Faculty of Medicine and Dentistry.

Glob J Health Sci 2012 Sep 10;4(6):109-18. Epub 2012 Sep 10.

University of Alberta, Alberta, Canada.

Nepal and Alberta are literally a world apart. Yet they share a common problem of restricted access to health services in remote and rural areas. In Nepal, urban-rural disparities were one of the main issues in the recent civil war, which ended in 2006. In response to the need for improved health equity in Nepal a dedicated group of Nepali physicians began planning the Patan Academy of Health Sciences (PAHS), a new health sciences university dedicated to the education of rural health providers in the early 2000s. Beginning with a medical school the Patan Academy of Health Sciences uses international help to plan, deliver and assess its curriculum. PAHS developed an International Advisory Board (IAB) attracting international help using a model of broad, intentional recruitment and then on individuals' natural attraction to a clear mission of peace-making through health equity. Such a model provides for flexible recruitment of globally diverse experts, though it risks a lack of coordination. Until recently, the PAHS IAB has not enjoyed significant or formal support from any single international institution. However, an increasing number of the international consultants recruited by PAHS to its International Advisory Board are from the University of Alberta in Edmonton, Alberta, Canada (UAlberta). The number of UAlberta Faculty of Medicine and Dentistry members involved in the project has risen to fifteen, providing a critical mass for a coordinated effort to leverage institutional support for this partnership. This paper describes the organic growth of the UAlberta group supporting PAHS, and the ways in which it supports a sister institution in a developing nation.
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http://dx.doi.org/10.5539/gjhs.v4n6p109DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4777003PMC
September 2012

Analysis of the status of Chinese clinical practice guidelines development.

BMC Health Serv Res 2012 Jul 25;12:218. Epub 2012 Jul 25.

Department of Educational Management, Friendship Hospital, CapitalMedical University, Beijing 100050, China.

Background: The work of developing clinical practice guidelines began just a little more than ten years ago in China. Up to now, there have been few studies about them.

Objectives: To review and analyze the status of Chinese clinical practice guidelines in 1997-2007.

Methods: All Chinese guidelines from 1997-2007 were collected, and made a regression analysis, and a citation analysis for evaluating the impact of guidelines. To analyze the developing quality, the most influential guidelines were evaluated with AGREE instrument, and each guideline was evaluated to check for any updating. In order to analyze the objective and target population, all guidelines were classified and counted separately according to disease/symptom center, and whether towards specialists or general practitioners.

Results: 143 guidelines were collected. An exponential function equation was established for the trend in the number of guidelines. The immediacy index in every year was very low while the average citation rate was not. Both the percentages of highly cited and never cited were high. For the evaluation with AGREE, only the average score of clarity and presentation was high (89.9%); the remaining were much lower. Editorial independence scored 0. Only 27 (18.9%) of 143 guidelines, were found to be evidence-based. Only a few had ever been updated, with an average updating interval of 5.2 years. Only 2.1% were symptom-centered, and only 4.2% were aimed at general practitioners.

Conclusion: Much progress has been obtained for Chinese guidelines development. However, there were still defects, and greater efforts should be made in the future.
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http://dx.doi.org/10.1186/1472-6963-12-218DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3502520PMC
July 2012

Resource utilization and cost analyses of home-based palliative care service provision: the Niagara West End-of-Life Shared-Care Project.

Palliat Med 2013 Feb 16;27(2):115-22. Epub 2012 Jan 16.

University of Toronto, Institute of Health Policy, Management and Evaluation, Canada.

Background: Increasing emphasis is being placed on the economics of health care service delivery - including home-based palliative care.

Aim: This paper analyzes resource utilization and costs of a shared-care demonstration project in rural Ontario (Canada) from the public health care system's perspective.

Design: To provide enhanced end-of-life care, the shared-care approach ensured exchange of expertise and knowledge and coordination of services in line with the understood goals of care. Resource utilization and costs were tracked over the 15 month study period from January 2005 to March 2006.

Results: Of the 95 study participants (average age 71 years), 83 had a cancer diagnosis (87%); the non-cancer diagnoses (12 patients, 13%) included mainly advanced heart diseases and COPD. Community Care Access Centre and Enhanced Palliative Care Team-based homemaking and specialized nursing services were the most frequented offerings, followed by equipment/transportation services and palliative care consults for pain and symptom management. Total costs for all patient-related services (in 2007 $CAN) were $1,625,658.07 - or $17,112.19 per patient/$117.95 per patient day.

Conclusion: While higher than expenditures previously reported for a cancer-only population in an urban Ontario setting, the costs were still within the parameters of the US Medicare Hospice Benefits, on a par with the per diem funding assigned for long-term care homes and lower than both average alternate level of care and hospital costs within the Province of Ontario. The study results may assist service planners in the appropriate allocation of resources and service packaging to meet the complex needs of palliative care populations.
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http://dx.doi.org/10.1177/0269216311433475DOI Listing
February 2013

Grand Challenges Canada: inappropriate emphasis and missed opportunities in global health research?

Can J Public Health 2011 Mar-Apr;102(2):149-51

Department of Pediatrics, University of British Columbia, Vancouver, BC.

In May 2010, Grand Challenges Canada (GCC) was launched with the mandate to identify global challenges in health that could be supported through the Government of Canada's Development Innovations Fund (DIF: $225 million over five years). The GCC offers a potentially excellent mechanism for taking Canada's participation in global health challenges "to a higher level". Recent GCC announcements raise new questions about the emphasis being placed on technological discovery or "catalytic" research. Missing so far are opportunities that the Fund could offer in order to support innovative research addressing i) health systems strengthening, ii) more effective delivery of existing interventions, and iii) policies and programs that address broader social determinants of health. The Canadian Grand Challenges announced to date risk pushing to the sidelines good translational and implementation science and early career-stage scientists addressing important social, environmental and political conditions that affect disease prevalence, progress and treatment; and the many unresolved challenges faced in bringing to scale proven interventions within resource-constrained health systems. We wish to register our concern at the apparent prioritization of biotechnical innovation research and the subordination of the social, environmental, economic and political context in which human health is either protected or eroded.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6973914PMC
July 2011

Strategic responses to fiscal constraints: a health policy analysis of hospital-based ambulatory physical therapy services in the Greater Toronto Area (GTA).

Physiother Can 2009 12;61(4):221-30; discussion 231-3. Epub 2009 Nov 12.

Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada.

Purpose: Ambulatory physical therapy (PT) services in Canada are required to be insured under the Canada Health Act, but only if delivered within hospitals. The present study analyzed strategic responses used by hospitals in the Greater Toronto Area (GTA) to deliver PT services in an environment of fiscal constraint.

Methods: Key informant interviews (n = 47) were conducted with participants from all hospitals located within the GTA.

Results: Two primary strategic responses were identified: (1) "load shedding" through the elimination or reduction of services, and (2) "privatization" through contracting out or creating internal for-profit subsidiary clinics. All hospitals reported reductions in service delivery between 1996 and 2003, and 15.0% (7/47 hospitals) fully eliminated ambulatory services. Although only one of 47 hospitals contracted out services, another 15.0% (7/47) reported that for-profit subsidiary clinics were created within the hospital in order to access other more profitable forms of quasi-public and private funding.

Conclusions: Strategic restructuring of services, aimed primarily at cost containment, may have yielded short-term financial savings but has also created a ripple effect across the continuum of care. Moreover, the rise of for-profit subsidiary clinics operating within not-for-profit hospitals has emerged without much public debate and with little research to evaluate its impact.
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http://dx.doi.org/10.3138/physio.61.4.221DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2793696PMC
August 2011

The impact of different benefit packages of Medical Financial Assistance Scheme on health service utilization of poor population in rural China.

BMC Health Serv Res 2010 Jun 17;10:170. Epub 2010 Jun 17.

Department of Social Medicine, School of Health Management, Harbin Medical University, 157 Baojian Road, Harbin City, Heilongjiang Province, China.

Background: Since 2003 and 2005, National Pilot Medical Financial Assistance Scheme (MFA) has been implemented in rural and urban areas of China to improve the poorest families' accessibility to health services. Local governments of the pilot areas formulated various benefit packages. Comparative evaluation research on the effect of different benefit packages is urgently needed to provide evidence for improving policy-making of MFA. This study was based on a MFA pilot project, which was one component of Health VIII Project conducted in rural China. This article aimed to compare difference in health services utilization of poor families between two benefit package project areas: H8 towns (package covering inpatient service, some designated preventive and curative health services but without out-patient service reimbursement in Health VIII Project,) and H8SP towns (package extending coverage of target population, covering out- patient services and reducing co-payment rate in Health VIII Supportive Project), and to find out major influencing factors on their services utilization.

Methods: A cross-sectional survey was conducted in 2004, which used stratified cluster sampling method to select poor families who have been enrolled in MFA scheme in rural areas of ChongQing. All family members of the enrolled households were interviewed. 748 and 1129 respondents from two kinds of project towns participated in the survey. Among them, 625 and 869 respondents were included (age>/=15) in the analysis of this study. Two-level linear multilevel model and binomial regressions with a log link were used to assess influencing factors on different response variables measuring service utilization.

Results: In general, there was no statistical significance in physician visits and hospitalizations among all the respondents between the two kinds of benefit package towns. After adjusting for major confounding factors, poor families in H8SP towns had much higher frequency of MFA use (beta = 1.17) and less use of hospitalization service (OR = 0.7 (H8SP/H8), 95%CI (0.5, 1.0)) among all the respondents. While calculating use of hospital services among those who needed, there was significant difference (p = 0.032) in percentage of hospitalization use between H8SP towns (46%) and H8 towns (33%). Meanwhile, the non-use but ought-to-use hospitalization ratio of H8SP (54%) was lower than that of H8 (67 %) towns. This indicated that hospitalization utilizations had improved in H8SP towns among those who needed. Awareness of MFA detailed benefit package and presence of physician diagnosed chronic disease had significant association with frequency of MFA use and hospitalizations. There was no significant difference in rate of borrowing money for illness treatment between the two project areas. Large amount of medical debt had strong association with hospitalization utilization.

Conclusions: The new extended benefit package implemented in pilot towns significantly increased the poor families' accessibility to MFA package in H8SP than that of H8 towns, which reduced poor families' demand of hospitalization services for their chronic diseases, and improved the poor population's utilization of out-patient services to some degree. It can encourage poor people to use more outpatient services thus reduce their hospitalization need. Presence of chronic disease and hospitalization had strong association with the presence of large amount of medical debt, which indicated that: although establishment of MFA had facilitated accessibility of poor families to this new system, and improved service utilization of poor families to some degree, but its role in reducing poor families' medical debt resulted from chronic disease and hospitalization was still very limited. Besides, the following requirements of MFA: co-payment for in-patient services, ceiling and deductibles for reimbursement, limitations on eligibility for diseases reimbursement, also served as most important obstacles for poor families' access to health care. Therefore, there is great need to improve MFA benefit package design in the future, including extending to cover out-patient services, raising ceiling for reimbursement, removing deductibles of MFA, reducing co-payment rate, and integrating MFA with New Rural Cooperative Medical Scheme more closely so as to provide more protection to the poor families.
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http://dx.doi.org/10.1186/1472-6963-10-170DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2909998PMC
June 2010

Achieving a dream: meeting policy goals related to improving drug access.

Open AIDS J 2010 Jan 19;4:25-7. Epub 2010 Jan 19.

Centre for International Health, Canada.

International experts recognize that significant inequities exist in the accessibility of life-saving medicines among poor and vulnerable populations, especially in developing countries. This article highlights that drug access even for relatively cheap medicines is out of reach for the vast numbers of global poor. This badly affects people living with HIV/AIDS who face serious obstacles in accessing ARVs. The same concerns are attributed to neglected diseases. Despite international meetings, promises from the pharmaceutical industry and a lot of media attention little has changed in the past 20 years. The accessibility gap to life-saving drugs could be reduced by the UNITAID initiative to pool patents for the many different ARVs, but the reality is that UNITAID is still a promise. To surmount this global problem of inequity requires a rethinking of traditional models of drug access and health objectives that should not be compromised by commercial interests.
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http://dx.doi.org/10.2174/1874613601004020025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2819694PMC
January 2010

Development of an effective public health screening program to assess hearing disabilities among newborns in Shanghai: a prospective cohort study.

World Health Popul 2009 ;11(1):14-23

Shanghai Municipal Health Bureau, 1477 Beijing West Road, Shanghai, China.

Background: An effective, systematic program of screening, diagnosis and intervention against hearing loss in infants could help them avoid developmental impediments and could help society stem preventable healthcare burdens. We assessed the feasibility and outcomes of a new public health universal newborn hearing screening program (UNHSP) for neonates born in Shanghai.

Methods: From March 2002 to June 2007, we conducted a two-stage hearing loss screening program for neonates born at all 105 delivery hospitals in Shanghai. Institutional participants in the program followed standardized testing criteria and procedures. The first stage of screening occurred in the hospital during the third day post-birth; positive infants underwent a second-stage outpatient screening on Day 42. Positive infants were examined at clinical diagnosis centres, and interventions were conducted at rehabilitation centres. In 2003, a random sample of parents were interviewed about the program, and their level of stress over learning their child screened positive were recorded and analyzed.

Findings: Overall, our program screened 72.98% of eligible infants and provided effective interventions within six months to 86.31% of those with hearing oss. During the 5-year study, first-stage screenings assessed 90.85% of 616,880 eligible infants and found 12.16% positive. Day 42 screenings had a 65.68% participation rate and a positive rate of 14.75%. Of these, 0.146% were deemed permanently hearing impaired within three months of birth. Parental satisfaction measures exceeded 90%.

Interpretation: A government-sponsored public health program to screen, diagnose, treat and provide interventions for all newborns with permanently hearing impairment can be effectively implemented and can achieve outcomes that surpass comparable clinical initiatives.
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March 2010

Re-positioning the role of traditional, complementary and alternative medicine as essential health knowledge in global health: do they still have a role to play?

World Health Popul 2008 ;10(4):62-75

Department of Health, Aging and Society, McMaster University; Centre for International Health, University of Toronto, Canada.

Traditional, complementary and alternative medicine (TCAM), drawn from indigenous medical and/or healing knowledge systems from around the world, has for the last 30 years been recognized by the World Health Organization (WHO) as providing culturally acceptable, affordable and sustainable primary healthcare. TCAM knowledge has been known for some time to assist with birthing practices, acute injuries, infectious diseases and parasites. Although the focus on TCAM began in earnest by the WHO in 1978, and was re-emphasized between 2002 and 2008, TCAM has for the most part been overlooked in large-scale international health programs. This paper follows recent global interest in TCAM and examines notable developments that have specific relevance for TCAM integration in global primary healthcare. Drawing on established work by Bodeker and others, we focus on how TCAM is used in the context of health promotion, disease prevention and the reduction of infectious diseases. Specific examples include the use of TCAM practitioners for HIV/AIDS prevention awareness and direct treatment of AIDS-related symptoms; the use of TCAM herbs for the treatment of malaria and the use of home herbal gardens for health maintenance. The final contribution of the paper helps to theorize inherent challenges and possible solutions to integrating TCAM into global health that have not been widely discussed to date.
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September 2009

Evaluation of a diabetes management program in China demonstrated association of improved continuity of care with clinical outcomes.

J Clin Epidemiol 2008 Sep 10;61(9):932-9. Epub 2008 Jul 10.

Nuffield Centre for International Health and Development, University of Leeds, 71-75 Clarendon Road, Leeds, West Yorks, UK.

Objective: The aim of the study was to evaluate a community-based diabetes management program in Shanghai, China and to examine the association between continuity of care and clinical outcomes.

Study Design And Setting: The diabetes management program was implemented in downtown Shanghai. One hundred fifty-six patients participated in the intervention group and 182 patients were in the control group. Participants were elders without severe diabetic complications. Patient weight, body mass index, blood pressures, and fasting blood glucose were collected from outpatient records at baseline and the end of the study in both groups. Fructosamine level was measured to monitor glycemic control for patients in the intervention group. Continuity of care was measured based on our broad definition.

Results: Improved patient health outcomes were observed in the diabetes management program: patients in the intervention group significantly reduced their weight, systolic blood pressure, and fasting blood glucose compared with those in the control group (P<0.05). In hierarchical regression models, continuity of care scales had a significant association with weight loss and fasting blood glucose reduction.

Conclusion: This study suggested that continuity based on broad terms can act as an important management tool to improve the quality of primary care in similar urban settings.
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http://dx.doi.org/10.1016/j.jclinepi.2007.12.013DOI Listing
September 2008

Assessing continuity of care in a community diabetes program: initial questionnaire development and validation.

J Clin Epidemiol 2008 Sep 10;61(9):925-31. Epub 2008 Jul 10.

Nuffield Centre for International Health and Development, University of Leeds, 71-75 Clarendon Road, Leeds, West York, UK.

Objective: To develop and validate a questionnaire based on agency theory to measure continuity of care in a community-based diabetes control program in Shanghai, China.

Study Design And Setting: Continuity of care was conceptualized in relation to two domains: information transfer and goal alignment. The questionnaire combined scales adopted from two validated questionnaires: the Primary Care Assessment Survey and the Summary of Diabetes Self-care Activities Measure. Patient interviews were conducted with 156 diabetes patients in the intervention group and 182 in the control group in two community health settings in Shanghai, China. The questionnaire was validated in terms of Likert-scaling assumptions, data completeness, score distribution, construct validity, and sensitivity.

Results: All scales consistently showed strong measurement properties in item reliability and validity. Requirements of data completeness and distribution were achieved in all scales. Principal components analysis of six scales provided a satisfactory explanation of the hypothesized scale-domain construction.

Conclusions: The validation results suggested that the scales in our continuity of care questionnaire are consistent with the concept of continuity of care based on agency theory.
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http://dx.doi.org/10.1016/j.jclinepi.2007.12.010DOI Listing
September 2008

Shifting sands: assessing the balance between public, private not-for-profit and private for-profit physical therapy delivery in Ontario, Canada.

Physiother Res Int 2008 Sep;13(3):189-99

Department of Physical Therapy, Faculty of Medicine, University of Toronto, 160-500 University Avenue, Toronto, Ontario, Canada.

Background And Purpose: The vast majority of health services within Canada's single payer universal health care system are publicly funded. Despite the highly political and controversial emphasis placed on public funding, the structure of delivery within this health care system does not require public ownership. In this research, we developed a conceptual framework for analysing the public and private mix of physical therapy (PT) delivery in the province of Ontario. We then applied this framework to examine the shifts in employment structure of physical therapists (PTs) in Ontario.

Methods: A two-phased health policy case study methodology was used. In the first phase, we reviewed publicly available documents and conducted a series of 30 key informant interviews in order to develop our framework. In the second phase, we applied the framework and performed secondary analysis of the provincial PT registration database to assess change in practice setting between 1996 and 2002.

Results: We identified nine models of delivery that fall into three categories of ownership structure: (a) public; (b) private not-for-profit; and (c) private for-profit. During the six-year period between 1996 and 2002, the relative proportion of PTs employed in the not-for-profit sector decreased (from 59.6% to 54.8%) whereas the share in the for-profit sector grew (from 40.4% to 45.2%).

Conclusions: The shifting balance in the structure of delivery may be transforming how PT services are provided in the province. Private for-profit providers appear to be increasing their market share; however, the outcomes relative to this shift has yet to be fully explored. Further policy and health services research is warranted to more fully understand the consequences of this shift on variables such as professional autonomy, access, cost and quality of services across Canada, but also within similar and dissimilar international jurisdictions.
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http://dx.doi.org/10.1002/pri.406DOI Listing
September 2008

The obstetric pathology of poverty: maternal mortality in Kep province, Cambodia.

World Health Popul 2007 Apr;9(2):38-47

Faculty of Arts and Science, University of Toronto, Canada.

Purpose: To conduct a baseline assessment study of maternal mortality in the province of Kep, Cambodia.

Methods: We evaluated maternal mortality in Kep using a structured questionnaire. The questionnaire was administered to women who were deemed the best respondents, and it included a verbal autopsy portion. The best respondent answered questions regarding a recent maternal death in the area, and the cause of death was identified.

Findings: Five maternal deaths were recorded in this study. Since 523 births were documented in the district for the last year, the maternal mortality rate for the province is 956/100,000. The cause of death for one woman was unknown. The other women most likely suffered from infection, eclampsia, postpartum hemorrhage and antepartum hemorrhage. The maternal mortality ratio may be an underestimate, given the stigma associated with reporting maternal deaths, especially when associated with traditional delivery practices.
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http://dx.doi.org/10.12927/whp.2007.18844DOI Listing
April 2007

China: policy and practice of MCH since the early 1990s.

Matern Child Health J 2008 Mar 27;12(2):139-48. Epub 2007 Nov 27.

School of Social Development and Public Policy, Fudan University, 220 Handan Road, Shanghai 200433, China.

Since the socioeconomic reforms in China in the late 1970s the improvement of maternal and child health (MCH), which was once considered one of the great achievements of China after 1949, has slowed and some indicators show that the situation in some regions, especially in rural areas, is getting worse instead of better. This article will focus on policy and policy-related issues in the delivery of MCH services. It will cover historical changes in policy and their effects, especially in the financing of MCH. In addition, it will also touch upon new practices of MCH in the new cooperative medical scheme (NCMS) in present-day rural China.
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http://dx.doi.org/10.1007/s10995-007-0305-1DOI Listing
March 2008

The Shanghai case: A qualitative evaluation of community health reform in response to the challenge of population ageing.

Int J Health Plann Manage 2005 Jul-Sep;20(3):269-86

Department of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Rm. 2260, MSB, 1 King's College Circle, Toronto, ON, Canada.

Shanghai's health care system is facing a serious challenge of an ageing population, as 14% of its 17 million residents are 65 or older. In 2000, a community health reform was implemented to provide comprehensive and continuous primary care to community residents with a focus on seniors. The study employed the theoretical framework of examining primary care in terms of the constellation of its four unique elements (first contact, comprehensiveness, longitudinality and coordination) and three healthcare components (structure, process and outcome). The study aimed to evaluate the extent to which the reform has achieved its process goals and how the organizational context influenced the level of implementation. In-depth interviews with 25 health providers, 15 seniors and four community leaders were carried out. The study found that the Shanghai community health reform has improved the structure and process of primary care regarding first contact, comprehensiveness and longitunality. However, the reform is constrained by structural barriers on seniors' financial access to resources and the capacity of primary care providers. The previous organization system also constrains the reform in CHCs financing and administration. The Shanghai case illustrates that a broad societal view has to be taken when analysing health reforms, which requires the involvement of multiple sectors including the government, health providers and health consumers.
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http://dx.doi.org/10.1002/hpm.814DOI Listing
September 2005

Global child and youth health.

Paediatr Child Health 2005 May;10(5):257

Division of Paediatric Medicine, The Hospital for Sick Children.

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2722538PMC
May 2005

Youth social action: building a global latticework through information and communication technologies.

Health Promot Int 2002 Dec;17(4):363-71

Department of Public Health Sciences, University of Toronto, Toronto, Canada.

New technologies and a growing global consciousness have created innovative opportunities for young people to connect locally, nationally and internationally for social action. This paper describes the dynamics of collective action in this new environment. Particular attention is given to how youth social action initiatives use information and communication technologies (ICT) to foster connection, action and sustainability. In-depth interviews were performed with five youths (aged 18-24 years) and two youth workers at two international non-government organizations (NGOs) focusing on social justice and human rights: Global Youth Connect and Amnesty International Canada. Qualitative methods were used to code and analyze the interview tapes and notes. Three main results are discussed: (i) the role of connection in building a youth action movement; (ii) the differential use of various communication technologies; and (iii) access barriers to connection opportunities. ICT enables new and expanded ways of connecting youth to express and share their experiences, which is a key success factor for social action initiatives.
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http://dx.doi.org/10.1093/heapro/17.4.363DOI Listing
December 2002
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