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

ABSTRACT: 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this systematic review we searched 52 electronic databases for published studies and 58 document inventories for unpublished studies from the 1960s to 2016.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.

SUBMITTER: Rowe AK

PROVIDER: S-EPMC6185992 | biostudies-literature | 2018 Nov

REPOSITORIES: biostudies-literature

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

Rowe Alexander K AK Rowe Samantha Y SY Peters David H DH Holloway Kathleen A KA Chalker John J Ross-Degnan Dennis D

The Lancet. Global health 20181008 11

<h4>Background</h4>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.<h4>Methods</h4>For this systematic review we searched 52 electronic databases for published studies and 58 document inventories for unpublished studies from the 196 ...[more]

PMID: 30309799

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Project description:BackgroundAlthough 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.MethodsWe 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.ResultsWe 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.ConclusionsAlthough 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.

Project description:BackgroundHealth 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.MethodsThe 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.ResultsWe 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.ConclusionsStudies 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.

Project description:BackgroundEach year almost 3 million newborns die within the first 28 days of life, 2.6 million babies are stillborn, and 287,000 women die from complications of pregnancy and childbirth worldwide. Effective and cost-effective interventions and behaviours for mothers and newborns exist, but their coverage remains inadequate in low- and middle-income countries, where the vast majority of deaths occur. Cost-effective strategies are needed to increase the coverage of life-saving maternal and newborn interventions and behaviours in resource-constrained settings.MethodsA systematic review was undertaken on the cost-effectiveness of strategies to improve the demand and supply of maternal and newborn health care in low-income and lower-middle-income countries. Peer-reviewed and grey literature published since 1990 was searched using bibliographic databases, websites of selected organizations, and reference lists of relevant studies and reviews. Publications were eligible for inclusion if they report on a behavioural or health systems strategy that sought to improve the utilization or provision of care during pregnancy, childbirth or the neonatal period; report on its cost-effectiveness; and were set in one or more low-income or lower-middle-income countries. The quality of the publications was assessed using the Consolidated Health Economic Evaluation Reporting Standards statement. Incremental cost per life-year saved and per disability-adjusted life-year averted were compared to gross domestic product per capita.ResultsForty-eight publications were identified, which reported on 43 separate studies. Sixteen were judged to be of high quality. Common themes were identified and the strategies were presented in relation to the continuum of care and the level of the health system. There was reasonably strong evidence for the cost-effectiveness of the use of women's groups, home-based newborn care using community health workers and traditional birth attendants, adding services to routine antenatal care, a facility-based quality improvement initiative to enhance compliance with care standards, and the promotion of breastfeeding in maternity hospitals. Other strategies reported cost-effectiveness measures that had limited comparability.ConclusionDemand and supply-side strategies to improve maternal and newborn health care can be cost-effective, though the evidence is limited by the paucity of high quality studies and the use of disparate cost-effectiveness measures.Trial registrationPROSPERO_ CRD42012003255.

Project description:BACKGROUND:Within our inquiry into the implementation of breastfeeding policy in Malawi, Care Groups have been mentioned as a means to improve maternal and child health and nutrition outcomes. The 'Care Group model' is an approach primarily used in international development settings, whereby social and behaviour changes are promoted through supported peer-to-peer (mostly mother-to-mother) knowledge sharing. The aim of most Care Groups is to promote improved infant nutrition, improve hygiene and increase the number of children who are fully vaccinated and exclusively breastfed for the first 6 months. The behavioural changes promoted by Care Groups (such as safe infant feeding, frequent hand washing, consistent mosquito net usage, providing suitable complementary foods from 6 months old) have the potential of averting preventable deaths particularly among children under five. While a variety of approaches are used to promote improved health and nutrition for children under five, the Care Groups model was best known and frequently referenced during our discussions with key stakeholders regarding the delivery at community level of Malawi's National Multi-Sector Nutrition Policy 2018-2022. A better understanding of how Care Groups achieve their social and behaviour change results and how community-based efforts are sustained can potentially help to ensure more effective planning and budgeting for Care Group interventions and enable greater sustainability and increased coverage of infant feeding support countrywide. This realist review is designed to improve our understanding of how, why, to what extent and under what circumstances Care Groups improve infant feeding practices in low- and middle-income countries (LMICs). METHODS AND ANALYSIS:A realist review is a theory-driven approach to evidence synthesis. To undertake this realist review, we will gather evidence by conducting peer-reviewed and grey literature database searches in order to find peer reviewed articles, programme guidelines and evaluation reports, among other texts, associated with the implementation of Care Groups in low- and middle-income countries. Our review process has five key steps: (1) locating existing theories; (2) searching for evidence in literature; (3) selecting articles and other suitable evidence; (4) extracting data, identifying configurations of context-mechanism-outcomes; and (5) synthesising the evidence, drawing conclusions. DISCUSSION:The results of this realist review will be written up according to RAMESES guidelines and disseminated through a stakeholder workshop in Malawi, through conference presentations and peer-reviewed publications. It is intended to improve the understanding of the potential and limits of working through Care Groups globally and among relevant Malawi Ministry of Health staff and the donor and NGO community, both internationally and within Malawi. This systematic review protocol has been submitted for registration on the PROSPERO database (receipt number: 170261).

Project description:Neonatal mortality remains a significant health problem in low-income settings. Low-cost essential newborn care (ENC) interventions with proven efficacy and cost-effectiveness exist but have not reached high coverage (≥90%). Little is known about the strategies used to implement these interventions or how they relate to improved coverage. We conducted a systematic review of implementation strategies and implementation outcomes for ENC in low- and low middle-income countries capturing evidence from five medical and global health databases from 1990 to 2018. We included studies of implementation of delayed cord clamping, immediate drying, skin-to-skin contact (SSC) and/or early initiation of breastfeeding implemented in the first hour (facility-based studies) or the 1st day (community-based studies) of life. Implementation strategies and outcomes were categorized according to published frameworks: Expert Recommendations for Implementing Change and Outcomes for Implementation Research. The relationship between implementation strategies and outcomes was evaluated using standardized mean differences and correlation coefficients. Forty-three papers met inclusion criteria. Interventions included community-based care/health promotion and facility-based support and health care provider training. Included studies used 3-31 implementation strategies, though the consistency with which strategies were applied was variable. Conduct educational meetings was the most frequently used strategy. Included studies reported 1-4 implementation outcomes with coverage reported most frequently. Heterogeneity was high and no statistically significant association was found between the number of implementation strategies used and coverage of ENC. This review highlights several challenges in learning from implementation of ENC in low- and low middle-income countries, particularly poor description of interventions and implementation outcomes. We recommend use of UK Medical Research Council guidelines (2015) for process evaluations and checklists for reporting implementation studies. Improved reporting of implementation research in this setting is necessary to learn how to improve service delivery and outcomes and thereby reduce neonatal mortality.

Project description:BackgroundThe widespread use of antibiotics plays a major role in the development and spread of antimicrobial resistance. However, important knowledge gaps still exist regarding the extent of their use in low- and middle-income countries (LMICs), particularly at the primary care level. We performed a systematic review and meta-analysis of studies conducted in primary care in LMICs to estimate the prevalence of antibiotic prescriptions as well as the proportion of such prescriptions that are inappropriate.Methods and findingsWe searched PubMed, Embase, Global Health, and CENTRAL for articles published between 1 January 2010 and 4 April 2019 without language restrictions. We subsequently updated our search on PubMed only to capture publications up to 11 March 2020. Studies conducted in LMICs (defined as per the World Bank criteria) reporting data on medicine use in primary care were included. Three reviewers independently screened citations by title and abstract, whereas the full-text evaluation of all selected records was performed by 2 reviewers, who also conducted data extraction and quality assessment. A modified version of a tool developed by Hoy and colleagues was utilized to evaluate the risk of bias of each included study. Meta-analyses using random-effects models were performed to identify the proportion of patients receiving antibiotics. The WHO Access, Watch, and Reserve (AWaRe) framework was used to classify prescribed antibiotics. We identified 48 studies from 27 LMICs, mostly conducted in the public sector and in urban areas, and predominantly based on medical records abstraction and/or drug prescription audits. The pooled prevalence proportion of antibiotic prescribing was 52% (95% CI: 51%-53%), with a prediction interval of 44%-60%. Individual studies' estimates were consistent across settings. Only 9 studies assessed rationality, and the proportion of inappropriate prescription among patients with various conditions ranged from 8% to 100%. Among 16 studies in 15 countries that reported details on prescribed antibiotics, Access-group antibiotics accounted for more than 60% of the total in 12 countries. The interpretation of pooled estimates is limited by the considerable between-study heterogeneity. Also, most of the available studies suffer from methodological issues and report insufficient details to assess appropriateness of prescription.ConclusionsAntibiotics are highly prescribed in primary care across LMICs. Although a subset of studies reported a high proportion of inappropriate use, the true extent could not be assessed due to methodological limitations. Yet, our findings highlight the need for urgent action to improve prescription practices, starting from the integration of WHO treatment recommendations and the AWaRe classification into national guidelines.Trial registrationPROSPERO registration number: CRD42019123269.

Dataset Information

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

Publications

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

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