| 1. |
- Engdahl Mtango, Sofia, et al.
(författare)
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Referral and admission to intensive care: A qualitative study of doctors practices in a Tanzanian university hospital
- 2019
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Ingår i: PLOS ONE. - : Public Library of Science. - 1932-6203. ; 14:10
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Tidskriftsartikel (refereegranskat)abstract
- Intensive care is care for critically ill patients with potentially reversible conditions. Patient selection for intensive care should be based on potential benefit but since demand exceeds availability, rationing is needed. In Tanzania, the availability of Intensive Care Units (ICUs) is very limited and the practices for selecting patients for intensive care are not known. The aim of this study was to explore doctors experiences and perceptions of ICU referral and admission processes in a university hospital in Tanzania.
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| 2. |
- Sawcer, Stephen, et al.
(författare)
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Genetic risk and a primary role for cell-mediated immune mechanisms in multiple sclerosis
- 2011
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Ingår i: Nature. - : Springer Science and Business Media LLC. - 0028-0836 .- 1476-4687. ; 476:7359, s. 214-219
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Tidskriftsartikel (refereegranskat)abstract
- Multiple sclerosis is a common disease of the central nervous system in which the interplay between inflammatory and neurodegenerative processes typically results in intermittent neurological disturbance followed by progressive accumulation of disability. Epidemiological studies have shown that genetic factors are primarily responsible for the substantially increased frequency of the disease seen in the relatives of affected individuals, and systematic attempts to identify linkage in multiplex families have confirmed that variation within the major histocompatibility complex (MHC) exerts the greatest individual effect on risk. Modestly powered genome-wide association studies (GWAS) have enabled more than 20 additional risk loci to be identified and have shown that multiple variants exerting modest individual effects have a key role in disease susceptibility. Most of the genetic architecture underlying susceptibility to the disease remains to be defined and is anticipated to require the analysis of sample sizes that are beyond the numbers currently available to individual research groups. In a collaborative GWAS involving 9,772 cases of European descent collected by 23 research groups working in 15 different countries, we have replicated almost all of the previously suggested associations and identified at least a further 29 novel susceptibility loci. Within the MHC we have refined the identity of the HLA-DRB1 risk alleles and confirmed that variation in the HLA-A gene underlies the independent protective effect attributable to the class I region. Immunologically relevant genes are significantly overrepresented among those mapping close to the identified loci and particularly implicate T-helper-cell differentiation in the pathogenesis of multiple sclerosis.
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| 3. |
- Schell, Carl Otto, et al.
(författare)
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The global need for essential emergency and critical care
- 2018
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Ingår i: Critical Care. - : BMC. - 1364-8535 .- 1466-609X. ; 22
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Tidskriftsartikel (övrigt vetenskapligt/konstnärligt)abstract
- Critical illness results in millions of deaths each year. Care for those with critical illness is often neglected due to a lack of prioritisation, co-ordination, and coverage of timely identification and basic life-saving treatments. To improve care, we propose a new focus on essential emergency and critical care (EECC)care that all critically ill patients should receive in all hospitals in the world. Essential emergency and critical care should be part of universal health coverage, is appropriate for all countries in the world, and is intended for patients irrespective of age, gender, underlying diagnosis, medical specialty, or location in the hospital. Essential emergency and critical care is pragmatic and low-cost and has the potential to improve care and substantially reduce preventable mortality.
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| 4. |
- Baker, Ulrika, et al.
(författare)
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Bottlenecks in the implementation of essential screening tests in antenatal care : Syphilis, HIV, and anemia testing in rural Tanzania and Uganda
- 2015
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Ingår i: International Journal of Gynecology & Obstetrics. - : Wiley. - 0020-7292 .- 1879-3479. ; 130 Suppl 1, s. S43-S50
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE: To identify and compare implementation bottlenecks for effective coverage of screening for syphilis, HIV, and anemia in antenatal care in rural Tanzania and Uganda; and explore the underlying determinants and perceived solutions to overcome these bottlenecks.METHODS: In this multiple case study, we analyzed data collected as part of the Expanded Quality Management Using Information Power (EQUIP) project between November 2011 and April 2014. Indicators from household interviews (n=4415 mothers) and health facility surveys (n=122) were linked to estimate coverage in stages of implementation between which bottlenecks can be identified. Key informant interviews (n=15) were conducted to explore underlying determinants and analyzed using a framework approach.RESULTS: Large differences in implementation were found within and between countries. Availability and effective coverage was significantly lower for all tests in Uganda compared with Tanzania. Syphilis screening had the lowest availability and effective coverage in both countries. The main implementation bottleneck was poor availability of tests and equipment. Key informant interviews validated these findings and perceived solutions included the need for improved procurement at the central level.CONCLUSION: Our findings reinforce essential screening as a missed opportunity, caused by a lack of integration of funding and support for comprehensive antenatal care programs.
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| 5. |
- Baker, Ulrika
(författare)
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Closing the quality gap : investigating health system bottlenecks and quality improvement strategies for maternal and newborn care in Sub Saharan Africa, focusing on Tanzania
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- BACKGROUND: Despite substantial gains in survival in the past three decades, around 200,000 maternal deaths, 1 million newborn deaths and 1 million stillbirths occur annually in Sub Saharan Africa (SSA). The majority of these could be averted by effective medical interventions, but implementation in the context of under-resourced health systems is a challenge. The content of care received by mothers and newborns is therefore often of poor quality and the discordance between increased utilisation of care without the expected corresponding gains in survival is referred to as the quality gap. Closing this quality gap demands an understanding of its underlying determinants, approaches to measure its characteristics and effective improvement strategies. AIM: To assess implementation bottlenecks in district health systems, and evaluate strategies to address these, in order to contribute to closing the quality gap in maternal and newborn care in Sub Saharan Africa. METHODS: Study I was a multiple case study comparing attributes related to use of Clinical Practice Guidelines (CPGs) for maternal health in Burkina Faso, Ghana and Tanzania, focusing on their content and format, using document review and key informant interviews. Study II was a cross-sectional study where household and health facility data was linked to estimate effective coverage, the extent to which interventions were implemented as intended, of five key maternal and newborn health interventions, and to identify bottlenecks in their implementation in rural Tanzania. Study III was a qualitative study using a grounded theory approach to analyse 17 health worker interviews, examining the underlying conditions for care provision and health workers’ perceptions of what constitutes quality of care (QoC). Study IV was a qualitative process evaluation of a collaborative quality improvement (QI) intervention in rural Tanzanian health facilities. Health workers’ perceptions of the components of the intervention was analysed through a deductive theory driven approach, utilising the i-PARIHS framework as a lens, to elucidate contributors to mechanisms of effect. RESULTS: While the content of national CPGs correlated well with WHO guidelines, deficiencies in their format in terms of usability and applicability may limit implementation by health workers in practice (Study I). Effective coverage of maternal and newborn health interventions varied between 3% and 49% in the target populations despite high utilisation of health services; the implementation bottlenecks being similar within, but different between, districts (Study II). Unpredictability was identified as the fundamental condition for maternal and newborn care provision and an important determinant of quality (Study III). The components of collaborative QI interpreted as contributing to mechanisms of effect were: (1) improvement topics with a high degree of fit with existing practice; (2) run-charts using local data to monitor progress; (3) mentoring and coaching in individual health facilities. (Study IV). CONCLUSIONS: Improving the format of CPGs for maternal and newborn care could increase their usability and applicability, and therefore implementation, by health workers in practice (Study I). Estimating effective coverage in conditional stages along an implementation pathway can help to identify bottlenecks within health systems. Differences between districts reveal the utility of analysing bottlenecks at this level (Study II). Increasing predictability of health facility readiness, and focusing on the experiences of health workers, should be prioritised in order to improve QoC (Study III). Focusing on intervention components which meet the perceived needs of health workers may enhance mechanisms of effect and result in greater improvements in QoC and could also be used to guide harmonisation between different QI approaches (Study IV).
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| 6. |
- Baker, Ulrika, et al.
(författare)
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Identifying implementation bottlenecks for maternal and newborn health interventions in rural districts of the United Republic of Tanzania
- 2015
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Ingår i: Bulletin of the World Health Organization. - 0042-9686 .- 1564-0604. ; 93:6, s. 380-389
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Tidskriftsartikel (refereegranskat)abstract
- Objective To estimate effective coverage of maternal and newborn health interventions and to identify bottlenecks in their implementation in rural districts of the United Republic of Tanzania. Methods Cross-sectional data from households and health facilities in Tandahimba and Newala districts were used in the analysis. We adapted Tanahashi's model to estimate intervention coverage in conditional stages and to identify implementation bottlenecks in access, health facility readiness and clinical practice. The interventions studied were syphilis and pre-eclampsia screening, partograph use, active management of the third stage of labour and postpartum care. Findings Effective coverage was low in both districts, ranging from only 3% for postpartum care in Tandahimba to 49% for active management of the third stage of labour in Newala. In Tandahimba, health facility readiness was the largest bottleneck for most interventions, whereas in Newala, it was access. Clinical practice was another large bottleneck for syphilis screening in both districts. Conclusion The poor effective coverage of maternal and newborn health interventions in rural districts of the United Republic of Tanzania reinforces the need to prioritize health service quality. Access to high-quality local data by decision-makers would assist planning and prioritization. The approach of estimating effective coverage and identifying bottlenecks described here could facilitate progress towards universal health coverage for any area of care and in any context.
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| 7. |
- Baker, Ulrika, et al.
(författare)
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Unpredictability dictates quality of maternal and newborn care provision in rural Tanzania : A qualitative study of health workers' perspectives
- 2017
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Ingår i: BMC Pregnancy and Childbirth. - : Springer Science and Business Media LLC. - 1471-2393 .- 1471-2393. ; 17
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Tidskriftsartikel (refereegranskat)abstract
- Background: Health workers are the key to realising the potential of improved quality of care for mothers and newborns in the weak health systems of Sub Saharan Africa. Their perspectives are fundamental to understand the effectiveness of existing improvement programs and to identify ways to strengthen future initiatives. The objective of this study was therefore to examine health worker perspectives of the conditions for maternal and newborn care provision and their perceptions of what constitutes good quality of care in rural Tanzanian health facilities. Methods: In February 2014, we conducted 17 in-depth interviews with different cadres of health workers providing maternal and newborn care in 14 rural health facilities in Tandahimba district, south-eastern Tanzania. These facilities included one district hospital, three health centres and ten dispensaries. Interviews were conducted in Swahili, transcribed verbatim and translated into English. A grounded theory approach was used to guide the analysis, the output of which was one core category, four main categories and several sub-categories. Results: `It is like rain' was identified as the core category, delineating unpredictability as the common denominator for all aspects of maternal and newborn care provision. It implies that conditions such as mothers' access to and utilisation of health care are unreliable; that availability of resources is uncertain and that health workers have to help and try to balance the situation. Quality of care was perceived to vary as a consequence of these conditions. Health workers stressed the importance of predictability, of `things going as intended', as a sign of good quality care. Conclusions: Unpredictability emerged as a fundamental condition for maternal and newborn care provision, an important determinant and characteristic of quality in this study. We believe that this finding is also relevant for other areas of care in the same setting and may be an important defining factor of a weak health system. Increasing predictability within health services, and focusing on the experience of health workers within these, should be prioritised in order to achieve better quality of care for mothers and newborns.
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