Objective This review evaluates the effectiveness of quality improvement (QI) strategies in reducing disparities in health and health care. Data sources We identified papers published in English between 1983 and 2011 from the MEDLINE® database, the Cumulative Index of Nursing and Allied Health Literature (CINAHL), Web of Science Social Science Index, and PsycINFO. Review methods All abstracts and full-text articles were dually reviewed. Studies were eligible if they reported data on effectiveness of QI interventions on processes or health outcomes in the United States such that the impact on a health disparity could be measured. The review focused on the following clinical conditions: breast cancer, colorectal cancer, diabetes, heart failure, hypertension, coronary artery disease, asthma, major depressive disorder, cystic fibrosis, pneumonia, pregnancy, and end-stage renal disease. It assessed health disparities associated with race or ethnicity, socioeconomic status, insurance status, sexual orientation, health literacy/numeracy, and language barrier. We evaluated the risk of bias of individual studies and the overall strength of the body of evidence based on risk of bias, consistency, directness, and precision. Results Nineteen papers, representing 14 primary research studies, met criteria for inclusion. All but one of the studies incorporated multiple components into their QI approach. Patient education was part of most interventions (12 of 14), although the specific approach differed substantially across the studies. Ten of the studies incorporated self-management; this would include, for example, teaching individuals with diabetes to check their blood sugar regularly. Most (8 of 14) included some sort of provider education, which may have focused on the clinical issue or on raising awareness about disparities affecting the target population. Studies evaluated the effect of these strategies on disparities in the prevention or treatment of breast or colorectal cancer, cardiovascular disease, depression, or diabetes. Overall, QI interventions were not shown to reduce disparities. Most studies have focused on racial or ethnic disparities, with some targeted interventions demonstrating greater effect in racial minorities--specifically, supporting individuals in tracking their blood pressure at home to reduce blood pressure and collaborative care to improve depression care. In one study, the effect of a language-concordant breast cancer screening intervention was helpful in promoting mammography in Spanish-speaking women. For some depression care outcomes, the collaborative care model was more effective in less-educated individuals than in those with more education and in women than in men. Conclusions The literature on QI interventions generally and their ability to improve health and health care is large. Whether those interventions are effective at reducing disparities remains unclear. This report should not be construed to assess the general effectiveness of QI in the health care setting; rather, QI has not been shown specifically to reduce known disparities in health care or health outcomes. In a few instances, some increased effect is seen in disadvantaged populations; these studies should be replicated and the interventions studied further as having potential to address disparities.

Closing the quality gap: revisiting the state of the science (vol. 3: quality improvement interventions to address health disparities).

While the most important factors associated with facility-based delivery (FBD) have been explored within individual countries in Africa, no systematic review has explored the factors associated with FBD across sub-Saharan Africa. A systematic search of the peer-reviewed literature was conducted to identify articles published in English from 1/1995-12/2011 that reported on original research conducted entirely or in part in sub-Saharan Africa and included a primary outcome variable of FBD, delivery location, or skilled birth attendance (SBA). Out of 1,168 citations identified, 65 met inclusion criteria. 62 of 65 were cross-sectional, and 58 of 65 relied upon household survey data. Fewer than two-thirds (43) included multivariate analyses. The factors associated with facility delivery were categorized as maternal, social, antenatal-related, facility-related, and macro-level factors. Maternal factors were the most commonly studied. This may be a result of the overwhelming reliance on household survey data – where maternal sociodemographic factors are likely to be well-represented and non-maternal factors may be less consistently and accurately represented. Multivariate analysis suggests that maternal education, parity / birth order, rural / urban residence, household wealth / socioeconomic status, distance to the nearest facility, and number of antenatal care visits were the factors most consistently associated with FBD. In conclusion, FBD is a complex issue that is influenced by characteristics of the pregnant woman herself, her immediate social circle, the community in which she lives, the facility that is closest to her, and context of the country in which she lives. Research to date has been dominated by analysis of cross-sectional household survey data. More research is needed that explores regional variability, examines longitudinal trends, and studies the impact of interventions to boost rates of facility delivery in sub-Saharan Africa.

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Drivers and deterrents of facility delivery in sub-Saharan Africa: a systematic review

Summary Sub-Saharan Africa has a disproportionate burden of disease and faces a major public-health challenge from non-communicable diseases. Although infectious diseases continue to afflict Africa, the proportion of the overall disease burden in sub-Saharan Africa attributable to cancer is rising. The region is predicted to have a greater than 85% increase in cancer burden by 2030. Approaches to minimise the burden of cancer in sub-Saharan Africa in the past few years have had little success because of low awareness of the cancer burden and a poor understanding of the potential for cancer prevention. Success will not be easy, and will need partnerships and bridges to be built across countries, economies, and professions. A strategic approach to cancer control in sub-Saharan Africa is needed to build on what works there and what is unique to the region. It should ideally be situated within strong, robust, and sustainable health-care systems that offer quality health care to all people, irrespective of their social or economic standing. However, to achieve this will need new leadership, critical thinking, investment, and understanding. We discuss the present situation in sub-Saharan Africa and propose ideas to advance cancer control in the region, including the areas of cancer awareness, advocacy, research, workforce, care, training, and funding.

Challenges and opportunities in cancer control in Africa: a perspective from the African Organisation for Research and Training in Cancer

Introduction: Child undernutrition is a major public health problem. One third of all undernourished children globally reside in Sub-Saharan Africa (SSA). The aim of this study was to systematically review studies to determine the factors associated with stunting, wasting and underweight in SSA and contribute to the existing body of evidence needed for the formulation of effective interventions. Methods: This systematic review was conducted using the 2015 Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines. Five computerized bibliographic databases were searched: Scopus, PubMed, PsycINFO, CINAHL and Embase. The included studies were rated using eight quality-appraisal criteria derived from the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) checklist: sample size, sampling methodology, response rate, outcome measures, statistical analyses, control for confounding, study limitation, and ethical consideration. Results: Of a total of 2810 articles retrieved from the five databases, 49 studies met our inclusion criteria. The most consistent factors associated with childhood stunting, wasting and underweight in SSA were: low mother’s education, increasing child’s age, sex of child (male), wealth index/SES (poor household), prolonged duration of breastfeeding (>12 months), low birth weight, mother’s age (<20 years), source of drinking water (unimproved), low mother’s BMI (<18.5), birth size (small), diarrhoeal episode, low father’s education and place of residence (rural). Conclusions: The factors that predispose a child to undernutrition are multisectoral. To yield a sustainable improvement in child nutrition in SSA, a holistic multi-strategy community-based approach is needed that targets the factors associated with undernutrition, thereby setting the region on the path to achieving the WHO global nutrition target by 2025.

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Stunting, Wasting and Underweight in Sub-Saharan Africa: A Systematic Review

Since 2000, the United Nations’ Millennium Development Goals, which included a goal to improve maternal health by the end of 2015, has facilitated significant reductions in maternal morbidity and mortality worldwide. However, despite more focused efforts made especially by low- and middle-income countries, targets were largely unmet in sub-Saharan Africa, where women are plagued by many challenges in seeking obstetric care. The aim of this review was to synthesise literature on barriers to obstetric care at health institutions in sub-Saharan Africa. This review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus databases were electronically searched to identify studies on barriers to health facility-based obstetric care in sub-Saharan Africa, in English, and dated between 2000 and 2015. Combinations of search terms ‘obstetric care’, ‘access’, ‘barriers’, ‘developing countries’ and ‘sub-Saharan Africa’ were used to locate articles. Quantitative, qualitative and mixed-methods studies were considered. A narrative synthesis approach was employed to synthesise the evidence and explore relationships between included studies. One hundred and sixty articles met the inclusion criteria. Currently, obstetric care access is hindered by several demand- and supply-side barriers. The principal demand-side barriers identified were limited household resources/income, non-availability of means of transportation, indirect transport costs, a lack of information on health care services/providers, issues related to stigma and women’s self-esteem/assertiveness, a lack of birth preparation, cultural beliefs/practices and ignorance about required obstetric health services. On the supply-side, the most significant barriers were cost of services, physical distance between health facilities and service users’ residence, long waiting times at health facilities, poor staff knowledge and skills, poor referral practices and poor staff interpersonal relationships. Despite similarities in obstetric care barriers across sub-Saharan Africa, country-specific strategies are required to tackle the challenges mentioned. Governments need to develop strategies to improve healthcare systems and overall socioeconomic status of women, in order to tackle supply- and demand-side access barriers to obstetric care. It is also important that strategies adopted are supported by research evidence appropriate for local conditions. Finally, more research is needed, particularly, with regard to supply-side interventions that may improve the obstetric care experience of pregnant women. PROSPERO 2014 CRD42014015549

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Access barriers to obstetric care at health facilities in sub-Saharan Africa—a systematic review

Background/Objective: Majority of the maternal deaths that occur especially in developing countries are avoidable or preventable. Studies have shown that the health, reproductive behaviour and socio economic status of women are among the important determinants of maternal mortality. This study was aimed at assessing the role of some health, socio-economic and demographic factors in determining the place of delivery among women in a semi-urban settlement in Zaria, north-western Nigeria. Method: The study design was a cross sectional descriptive study conducted in Sabuwar Unguwa, Magume district Zaria Local Government Area Kaduna State Nigeria in June, 2003. A total of 496 women who had delivered at least once were interviewed using a pre-tested interviewer administered questionnaire. Results: The study revealed both high rates of home deliveries and deliveries not supervised by skilled attendants of 70% and 78% respectively. Mother's educational level, husband's occupation and age at first pregnancy were the main determinants of place of delivery. Statistically significant associations between non- formal education and home delivery, (X 2 = 6.7 df = 1 P 2 =18.7 df = 1 P 2 = 0.59 df = 1 P>0.05). Conclusion: Low maternal education, unemployment among fathers, first pregnancies at less than 18 years of age increase the likelihood of home delivery in Sabuwar Unguwa, Magume district of Zaria. Girl child education, income generating activities and training of TBAs could reduce the high rate of home deliveries and its consequences in the study area. Keywords: Delivery, place, determinants Annals of African Medicine Vol. 5(2) 2006: 68-72

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Determinants of place of delivery among women in a semi-urban settlement in Zaria, northern Nigeria

Background: Carcinoma of the breast is an important public health problem in Nigeria and studies have reported low levels of awareness and practice of breast self examination as an important method of prevention. Breast self examination is a cost-effective method of early detection of cancer of the breast especially in resource poor countries. We assessed knowledge and practice of breast-self examination (BSE) among female undergraduate students of Ahmadu Bello University Zaria, Nigeria. Method: In this study, knowledge and practice of BSE were examined among 221 female students aged 16 – 28 years old studying at Ahmadu Bello University Zaria using self administered questionnaires. Results: It was found that despite nearly three quarter of the respondents (87.7%) had heard of BSE, only 19.0% of them were performing this examination monthly. Regarding the sources of information about BSE among respondents, media was found to be most common followed by health workers accounting for 45.5% and 32.2% respectively. Regular performance of BSE was significantly correlated with duration of stay in the University (X 2 = 81.9, df = 3, P < .05) and family history of breast cancer (X 2 = 17.4, df = 2, P < .05).

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Knowledge and practice of breast-self examination among female undergraduate students of Ahmadu Bello University Zaria, northwestern Nigeria.

Background: Low level of utilisation of maternal health services is a major factor responsible for high maternal mortality in northwestern region of Nigeria This study was aimed at determining the barriers to utilisation of maternal health services from the perspective of mothers in northwestern Nigeria Materials and Methods: A cross-sectional study of 150 mothers, selected through multistage technique, was conducted Data were collected using a structured interviewer-administered questionnaire, and analysed using SPSS statistics 170 Results: Only 27% utilised preconception service, 987% antenatal care service (ANC), 240% delivery, 353% postnatal care and 140% utilised family planning service Major reasons for non-utilisation of delivery service were not having a delivery complication in the past (57% (CI = 474-661)) and negative provider attitude (237% (CI = 164-327)) For non-utilisation of postnatal care, the major reasons were also not having a postnatal complication in the past (608% (CI = 504-704)) and negative provider attitude (278% (CI = 194-380)) As for non-utilisation of family planning service, the major reason was desire to have more children (326% (CI = 247-414)) Reasons for non-use of preconception care and ANC were not computed because respondents to these questions were not enough; only 6 (40%) were aware of preconception care in the first place and only 2 (13%) were not using ANC Conclusion: Despite living near a health facility, most of the mothers were not using maternal health services It is recommended that while there is the need to raise awareness on the utilisation of maternal health services, bring it closer to the mothers and make it more affordable, there is a more pressing need to improve its quality, especially through the alleviation of negative attitude of health care providers

Barriers to utilisation of maternal health services in a semi-urban community in northern Nigeria: The clients' perspective.

Background: Widespread epidemics of yellow fever and cerebrospinal meningitis across the African sub region in the 1990s were largely attributed to poor surveillance systems which were neither able to detect communicable diseases on time nor mount an effective response. Effective communicable disease control relies on effective response systems which are dependent upon effective disease surveillance. Integrated Disease Surveillance and Response strategy (IDSR) was adopted by the AFRO members of the World Health Organization (WHO) to improve surveillance activities. Aim: This study was conducted to assess IDSR implementation in selected Local Government Areas (LGAs) of Kaduna state. Settings and Design: Kaduna state is located in Northern Nigeria. It shares borders with the states of Sokoto, Katsina, Niger, Kano, Bauchi and Plateau. Based on the 2006 census projections, it has a population of 6.63 million. The study was a cross-sectional descriptive study. Materials and Methods: An interviewer administered questionnaire of an adaptation of the World Health Organization Protocol for the Assessment of National Communicable Disease Surveillance and Response systems was used. Data analysis was carried out using Epi Info statistical package version 3.5.1. Results: About a third of the health facilities (38%) did not have any case definition for the priority diseases. About 76% of the health facilities had electricity available from the National Grid. Seventy one percent have standby generators, out of which 67% were functional. Sixty two percent of health facilities had calculators available for data management while 29% had computers and printers available. No form of data analysis was available in 81% of the health facilities, analysis of data were however available in all 3 LGAs studied. A reporting system was available in 57% of health facilities. Thirteen percent of the health facilities reported receiving feedback from the LGAs. There was no feedback from the state to the LGAs, nor was there feedback from the national to the state level. Conclusion: The implementation of IDSR in Kaduna state is poor. Resources are insufficient and although some structures are present on ground like the presence of reporting mechanism, feedback is poor from the higher to lower levels. Standard case definitions are not used in all health facilities for all priority diseases. Standard case definitions should be made available and used in all health facilities.

Assessment of integrated disease surveillance and response strategy implementation in selected Local Government Areas of Kaduna state

Background : The use of Marijuana is on the increase worldwide especially among adolescents and youths. Marijuana smoking has gained a foothold in our environment because of peer group influence, accessibility and availability. Its medico-social effects could ruin the life and future of our youths. This study was undertaken to determine the prevalence and the factors that influence secondary school students in Zaria LGA to smoke and the effects on academic performance. Methods: A cross-sectional descriptive study was employed to generate data among secondary school students. A multi-stage sampling technique was used. Data was collected with the use of a structured, pre tested self-administered questionnaire. ƒO2 test was used to test for significance of association between categorical variables. Results: Of the 350 respondents, 262 (74.9%) were males, while 88 (25.1%) were females. The study shows that 33 of the students smoke marijuana giving a prevalence of 9.4%. There were more smokers in the age group 15-19 years (54.6%). Other factors that influence marijuana smoking include family background, peer pressure and attendance of social functions. There was better academic performance (51.1%) among non smokers as compared to smokers (27.2%), and this was found to be statistically significant (x2 = 11.73,df = 5,P program should be instituted to curtail this menace

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SH Idris

Papers

Determinants of place of delivery among women in a semi-urban settlement in Zaria, northern Nigeria

Knowledge and practice of breast-self examination among female undergraduate students of Ahmadu Bello University Zaria, northwestern Nigeria.

Barriers to utilisation of maternal health services in a semi-urban community in northern Nigeria: The clients' perspective.

Assessment of integrated disease surveillance and response strategy implementation in selected Local Government Areas of Kaduna state

Marijuana smoking among secondary school students in Zaria, Nigeria: factors responsible and effects on academic performance.