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.

/pdf/drivers-and-deterrents-of-facility-delivery-in-sub-saharan-1c4u6ucya5.pdf

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

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

/pdf/access-barriers-to-obstetric-care-at-health-facilities-in-4k491antaf.pdf

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

Breast cancer management in middle-resource countries (MRCs): Consensus statement from the Breast Health Global Initiative

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

/pdf/determinants-of-place-of-delivery-among-women-in-a-semi-o08yp95hix.pdf

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).

/pdf/knowledge-and-practice-of-breast-self-examination-among-12hs934gx8.pdf

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

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 (877%) had heard of BSE, only 190% 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 455% and 322% respectively Regular performance of BSE was significantly correlated with duration of stay in the University (X2 = 819, df = 3, P < 05) and family history of breast cancer (X2 = 174, df = 2, P < 05) Conclusion: We observed a disparity between high levels of knowledge of BSE compared to a low level of practice Public health education using the media could significantly reduce the knowledge- practice gap and early detection of breast lum

/pdf/knowledge-and-practice-of-breast-self-examination-among-4ryrx1g04r.pdf

U. M. D. Gwarzo

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.

Knowledge and practice of breast self-examination among female undergraduate students.