David Zakus

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

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.

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

BackgroundThe 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.MethodsA 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.ResultsFrom 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.DiscussionThis 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.ConclusionThe 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.

Performing arts as a social technology for community health promotion in northern Ghana

Objective We present first-phase results of a performing arts public health intervention, ‘Singing and Dancing for Health,’ aiming to promote healthier behaviors in Ghana’s impoverished Northern Region. We hypothesize that live music and dance drama provide a powerful technology to overcome barriers such as illiteracy, lack of adequate media access, inadequate health resources, and entrenched sociocultural attitudes. Our research objective is to evaluate this claim. Methods In this first phase, we evaluated the effectiveness of arts interventions in improving knowledge and behaviors associated with reduced incidence of malaria and cholera, focusing on basic information and simple practices, such as proper hand washing. Working with the Youth Home Cultural Group, we codeveloped two ‘dance dramas’ delivering health messages through dialog, lyrics, and drama, using music and dance to attract spectators, focus attention, infuse emotion, and socialize impact. We also designed knowledge, attitude, and behavior surveys as measurement instruments. Using purposive sampling, we selected three contrasting test villages in the vicinity, contrasting in size and demographics. With cooperation of chiefs, elders, elected officials, and Ghana Health Service officers, we conducted a baseline survey in each village. Next, we performed the interventions, and subsequently conducted follow-up surveys. Using a more qualitative approach, we also tracked a select subgroup, conducted focus group studies, and collected testimonials. Surveys were coded and data were analyzed by Epi Info. Results Both quantitative and qualitative methods indicated that those who attended the dance drama performances were likelier than those who did not attend to list the causal, preventive, and transmission factors of malaria and cholera. Also, the same attendees were likelier than nonattendees to list some activities they do to prevent malaria, cholera, and other sanitation-related diseases, proving that dance dramas were highly effective both in raising awareness and in transforming behaviors. Conclusions As a result of this study, we suggest that where improvements in community health depend primarily on behavioral change, music and associated performing arts – dancing, singing, and drama – presented by a professional troupe offer a powerful social technology for bringing them about. This article is a status report on the results of the project so far. Future research will indicate whether local community–based groups are able to provide equal or better outcomes at lower cost, without outside support, thus providing the capacity for sustainable, localized health promotion.

‘Feeling of despair’ as the leading cluster theme of conceptual descriptive analyses in participatory assessment: Russia Oxfam GB case study

This article provides a case study on participatory assessment based on experience gained from an EU–Oxfam GB project entitled “Empowering Municipalities to Effectively Address Poverty” conducted in five small towns in Russia. Participatory assessment through focus group discussions (FGDs) was the main approach used in the implementation of the project. A participatory assessment was performed through 25 FGDs in five remote areas in central Russia. More than 200 participants representing people living in poverty, such as single mothers, people with disabilities, families with many children, families with disabled children, and pensioners, voluntarily participated in the meetings. Most of the participants were women (75%) aged between 25 and 70 years. We consider that the participants’ representation is relevant in accordance with the official poverty studies. Through identification of patterns of recurrent ideas and opinions, a qualitative method helps us understand social phenomena from the views of and on the basis of the opinions of the participants. The FGDs’ narratives underwent pattern analysis, resulting in the framing of the cluster themes and narrative conceptualization. Cluster analysis of the FGDs’ narratives led to the framing of 10 cluster themes of importance, followed by conceptual descriptions and related narratives. The conceptual description of the leading theme, feeling of despair (theme 1), was described by respondents’ expressions/narratives, such as “Nobody needs us and there is no future for us and our children in this town,” the narrative idea that crosscuts the subsequent themes. The following nine themes are of equal importance, are interlinked, and for the major part constitute the leading theme, feeling of despair (theme 1): state social and family support (theme 2); health care (theme 3); who are those living in poverty? (theme 4); housing (theme 5); living costs (theme 6); employment (theme 7); children’s well-being and future (theme 8); environment and recreation (theme 9); and legal rights (theme 10). Equal importance of these themes is justified by the analysis of patterns and recurrence of the FGDs’ narrative ideas. The assigned numbers from 2 to 10 are given to simplify the references to the corresponding cluster throughout the analysis and do not reflect the ranks of the clusters. The leading theme (theme 1) touches on the psychological status of the FGDs’ participants, while the remaining nine themes (themes 2–10) relate to the state system of social services, including health care. For example, per the conceptual descriptions, the state social and family support (theme 2) is described by the following narrative: “Those who have a family network get their support, for those without family help, state support is crucial but is very little and not everybody can get it. Nobody wants to help or provide decent services – people in local government get fed up with you, you get sent from one place to another.” The frustration (“Nobody wants to help or provide decent services; the government gets fed up with you, you get sent from one place to another.”) caused by poor services (“State support is crucial but is very little and not everybody can get it.”) crosscuts the theme’s conceptual description. In this article, feeling of despair refers to a psychosocial condition caused by people living in poverty and their dissatisfaction with state services. Details of the remaining themes are given. The purpose of this article is to draw the attention of practitioners and policy makers to the participatory results rather than their focusing on the qualitative methodological details. We argue that a participatory understanding of community needs, through cluster theme analysis and conceptual descriptions, can help local municipalities develop more targeted community programs on poverty and vulnerability reduction.

Factors associated with the utilization of institutional and home birth services among women in Ethiopia: A scoping review

Objective To examine the factors associated with the use of institutional delivery and home birth services among women in Ethiopia. Methods Fifteen peer-reviewed, primary research articles published between 2011 and 2015 were selected for this scoping review. The articles included case-control, cross-sectional, and retrospective follow-up studies conducted in Ethiopia. Results Findings were categorized with use of content and factorial analysis. The data in this scoping review revealed a significant inequality in skilled care use among Ethiopian women with differences in economic status, education, residence, autonomy in decision making, parity, and antenatal care attendance. Conclusion Sociodemographic, accessibility, and obstetric factors are key determinants of skilled care utilization. Strategies and policy changes to address maternal health service use should aim to improve economic status, facilitate higher education, increase access to care, promote the empowerment of women, and enhance antenatal care initiatives. Additional research should be conducted to evaluate the influence of the media and culture on skilled care utilization, since few studies have examined these factors.

Unregulated health care workers in the care of aging populations: Similarities and differences between Brazil and Canada

Introduction The world’s population is rapidly aging. Unregulated health care workers (UHCWs) are emerging as a potentially important workforce in the care of older adults. Objective A review was conducted to identify the activities of UHCWs with respect to contributions and limitations. Methods A systematic integrative literature review was conducted using online databases (LILACS, PubMed, EMBASE, CINAHL, and grey literature). The inclusion criteria were as follows: (i) description of UHCW activities related to older adults; and (ii) description of UHCW activities performed in Brazil or Canada. Results Eleven papers were included in this review. In both countries, UHCW activities included health promotion, mental health care, and rehabilitation. In Brazil, UHCWs performed integrated care, while in Canada UHCWs performed personal care and housekeeping. Conclusion These results highlight the potential and limits of UHCWs who provide care for the aging population. Such information is important to health and social policy making and household decision making.

Long-term care for aged ethnic minority people in Yunnan, China: Understanding the situation

Chinese governmental sectors have been investing lots of money in setting up new institutions for long-term care (LTC) in rural China to respond to the predicted increasing and urgent needs of the growing number of aging people. However, very few have identified that many ethnic minority groups have been enjoying their traditional home-based LTC systems, which are cost-effective and have been working really well for generations. This article reports on a study on LTC needs and provisions for the Dai, one of the ethnic minority groups in rural areas of southwest China, in Yunnan (Province). A randomized sample was drawn from 12 villages in Ruili, a county 752 km from Kunming, the capital city of Yunnan. Totally, 187 elderly persons were interviewed intensively. Activities of daily living were measured as the core indicator for understanding LTC. The research revealed that there is a significant disparity between the needs of the villagers and provisions from the different levels of government. There is an urgent need to reexamine the allocation of public resources for the aged. Traditional culture and practices of caring for the elderly, and practices in LTC of different ethnic groups, must be carefully considered.