Health System Challenges in Organizing Quality Diabetes Care for Urban Poor in South India

Background

Weak health systems in low- and middle-income countries are recognized as the major constraint in responding to the rising burden of chronic conditions. Despite recognition by global actors for the need for research on health systems, little attention has been given to the role played by local health systems. We aim to analyze a mixed local health system to identify the main challenges in delivering quality care for diabetes mellitus type 2.

Methods

We used the health system dynamics framework to analyze a health system in KG Halli, a poor urban neighborhood in South India. We conducted semi-structured interviews with healthcare providers located in and around the neighborhood who provide care to diabetes patients: three specialist and 13 non-specialist doctors, two pharmacists, and one laboratory technician. Observations at the health facilities were recorded in a field diary. Data were analyzed through thematic analysis.

Result

There is a lack of functional referral systems and a considerable overlap in provision of outpatient care for diabetes across the different levels of healthcare services in KG Halli. Inadequate use of patients’ medical records and lack of standard treatment protocols affect clinical decision-making. The poor regulation of the private sector, poor systemic coordination across healthcare providers and healthcare delivery platforms, widespread practice of bribery and absence of formal grievance redress platforms affect effective leadership and governance. There appears to be a trust deficit among patients and healthcare providers. The private sector, with a majority of healthcare providers lacking adequate training, operates to maximize profit, and healthcare for the poor is at best seen as charity.

Conclusions

Systemic impediments in local health systems hinder the delivery of quality diabetes care to the urban poor. There is an urgent need to address these weaknesses in order to improve care for diabetes and other chronic conditions.     

Identifying Elements of Patient-Centered Care in Underserved Populations: A Qualitative Study of Patient Perspectives

Patient-centered care is an important goal in the delivery of healthcare. However, many patients do not engage in preventive medical care. In this pilot study, we conducted twenty in depth, semi-structured qualitative interviews at the University of Illinois at Chicago Health Sciences campus in a four month time frame. Many patients were underserved and underinsured, and we wanted to understand their experiences in the healthcare system. Using content analysis, several themes emerged from the interview data. Participants discussed the need for empathy and rapport with their providers. They identified provider behaviors that fostered a positive clinical relationship, including step-by step explanations of procedures, attention to body language and clinic atmosphere, and appropriate time management. Participants identified cost as the most common barrier to engaging in preventive care and discussed children and social support as motivating factors. A long-term relationship with a provider was an important motivator for preventive care, suggesting that the therapeutic alliance was essential to many patients. Conversely, many participants discussed a sense of dehumanization in the healthcare system, reporting that their life circumstances were overlooked, or that they were judged based on insurance status or ethnicity. We discuss implications for provider training and healthcare delivery, including the importance of patient-centered medical homes.     

The "amazing" fertility decline: Islam, economics, and reproductive decision making among working-class Moroccan women

Often it is understood that Islam prohibits family planning because the Qur'an does not explicitly address contraception. Public health and development officials have recently congratulated the Muslim world for decreases in fertility given the supposed constraints placed on reproductive healthcare by Islam, while popular culture writers have warned the West of threats by young Muslims if the population goes uncontrolled. This article draws on data collected through interviews with working-class women seeking reproductive healthcare at clinics in Rabat, Morocco, and with medical providers to challenge the link between Islamic ideology and reproductive practices and the correlation among Islam, poverty, and fertility. Morocco, a predominantly Muslim country, has experienced a dramatic decrease in fertility between the 1970s and today. I argue that patients and providers give new meanings to modern reproductive practices and produce new discourses of reproduction and motherhood that converge popular understandings of Islam with economic conditions of the Moroccan working class.     

Conscientious Objection in Healthcare Provision: A New Dimension

The right to conscientious objection in the provision of healthcare is the subject of a lengthy, heated and controversial debate. Recently, a new dimension was added to this debate by the US Supreme Court's decision in Burwell vs. Hobby Lobby et al. which effectively granted rights to freedom of conscience to private, for‐profit corporations. In light of this paradigm shift, we examine one of the most contentious points within this debate, the impact of granting conscience exemptions to healthcare providers on the ability of women to enjoy their rights to reproductive autonomy. We argue that the exemptions demanded by objecting healthcare providers cannot be justified on the liberal, pluralist grounds on which they are based, and impose unjustifiable costs on both individual persons, and society as a whole. In doing so, we draw attention to a worrying trend in healthcare policy in Europe and the United States to undermine women's rights to reproductive autonomy by prioritizing the rights of ideologically motivated service providers to an unjustifiably broad form of freedom of conscience.     

Professional Hubris and its Consequences: Why Organizations of Health‐Care Professions Should Not Adopt Ethically Controversial Positions

In this article, I argue that professional healthcare organizations such as the AMA and ANA ought not to take controversial stances on professional ethics. I address the best putative arguments in favor of taking such stances, and argue that none are convincing. I then argue that the sort of stance‐taking at issue has pernicious consequences: it stands to curb critical thought in social, political, and legal debates, increase moral distress among clinicians, and alienate clinicians from their professional societies. Thus, because there are no good arguments in favor of stance‐taking and at least some risks in doing so, professional organizations should refrain from adopting the sort of ethically controversial positions at issue.     

Parental Moral Distress and Moral Schism in the Neonatal ICU

Ethical dilemmas in critical care may cause healthcare practitioners to experience moral distress: incoherence between what one believes to be best and what occurs. Given that paediatric decision-making typically involves parents, we propose that parents can also experience moral distress when faced with making value-laden decisions in the neonatal intensive care unit. We propose a new concept—that parents may experience “moral schism”—a genuine uncertainty regarding a value-based decision that is accompanied by emotional distress. Schism, unlike moral distress, is not caused by barriers to making and executing a decision that is deemed to be best by the decision-makers but rather an encounter of significant internal struggle. We explore factors that appear to contribute to both moral distress and “moral schism” for parents: the degree of available support, a sense of coherence of the situation, and a sense of responsibility. We propose that moral schism is an underappreciated concept that needs to be explicated and may be more prevalent than moral distress when exploring decision-making experiences for parents. We also suggest actions of healthcare providers that may help minimize parental “moral schism” and moral distress.     

Medicine’s collision with false hope: The False Hope Harms (FHH) argument

The goal of this paper is to introduce the false hope harms (FHH) argument, as a new concept in healthcare. The FHH argument embodies a conglomerate of specific harms that have not convinced providers to stop endorsing false hope. In this paper, it is submitted that the healthcare profession has an obligation to avoid collaborating or participating in, propagating or augmenting false hope in medicine. Although hope serves important functions—it can be ‘therapeutic’ and important for patients’ ‘self-identity as active agents’— the presentation of false hope along the hope continuum entails a misconstrued balancing act. By not speaking up against unrealistic patient and family requests—including some requests for rights to try, resuscitative efforts in terminally ill patients, or other demands for non-beneficial treatments—healthcare providers precipitate harms, i.e., the FHH. These harms arise on both individual and communal levels and cannot be ignored. The goal of this paper is not to offer a definition of false hope, because the phenomenon of false hope is too complex for any simple definition. Instead, this paper seeks to make four points while outlining the FHH argument: consumer medicine and false hope are connected; providers and patients are very vulnerable in the system of consumer medicine; providers have a responsibility to stand up against false hope; and how the FHH argument could perhaps offer a footing to resist giving in to false hope.     

Towards remote monitoring and remotely supervised training

The growing number of elderly and people with chronic disorders in our western society puts such a pressure on our healthcare system that innovative approaches are required to make our health care more effective and more efficient. One way of innovating healthcare can be obtained by introducing new services that support and enable these elderly and people with chronic disorders in a more independent living and in self management with respect to their disorders. Examples of such services are remote monitoring and remotely supervised training (together RMT). Remote monitoring focuses on continuous monitoring of the health status with the assurance of assistance whenever required. Remotely supervised training focuses on efficient and effective individually tailored training anywhere and anytime with intensity not feasible in an intramural setting. It is expected that services of remote monitoring and remotely supervised treatment will become important for at least patients (safety, more in control, convenience), health care insurances (efficiency, cost reduction) and healthcare service providers (more effective care).RMT systems are in general quite complex distributed Information and Communication Technology (ICT) systems. RMT systems integrate ambulant sensing to measure relevant biosignals and (possibly) subject’s context information, secure data transport and storage, appropriate decisions support systems to assist in both technical and clinical decision making but also feedback on information to both patients and care providers. Feedback is essential for patients to make them aware of their health status, to give them a feeling of safety and to motivate and enable them to change/improve their health status. Feedback of information to healthcare professionals enables them in making appropriate decisions and to monitor changes/improvements in a patient’s health status.Despite this apparent complexity, these systems must be very dependable to be accepted and used in a healthcare setting. During the past years knowledge and experience has been gained with the development of the building blocks of RMT systems. In parallel, experience has been gained with respect to the challenges involved when using RMT systems in a clinical environment. Examples are: activity monitoring in low back pain, monitoring of spasticity, myofeedback in subjects with neck shoulder and lower back pain and post rehabilitation home training. Until now, the main focus has been on the technical realization of the sensing and transportation part of it. The development of intelligent decision support systems is still in its infancy and clinical validation studies and models how to implement these services and how to make them profitable are largely lacking.In conclusion, the combination of Biomedical Engineering with Information and Communication Technology has opened a new extensive area of research and development with a high potential to have substantial impact on our future healthcare.     

Adult attention deficit hyperactivity disorder: translating research into practice

Attention deficit hyperactivity disorder (ADHD) in adults is a prevalent, yet under-appreciated, under-researched and poorly understood condition. Given this, it is imperative that information and awareness regarding this condition are made more widespread, both amongst the general public and amongst healthcare professionals. Further, given our poor understanding of the aetiology of the condition, meaningful translational research that migrates into and better informs clinical practice must be a priority. In this brief review we highlight areas regarding the clinical diagnosis and management of ADHD in adults (guidelines, rating scales, pharmacotherapy, psychotherapy) as well as areas of promising translational research (genetics, neuroimaging, sleep and circadian rhythms, animal models of ADHD). We address some of the challenges presented for both clinicians and healthcare providers and research scientists working to improve the lives of those adults with ADHD.     

Patients with multiple needs for healthcare and priority to the worse off

There is a growing body of literature which suggests that decisions about healthcare priority setting should take into account the extent to which patients are worse off. However, such decisions are often based on how badly off patients are with respect to the condition targeted by the treatment whose priority is under consideration (condition‐specific severity). In this paper I argue that giving priority to the worse off in terms of condition‐specific severity does not reflect the morally relevant sense of being worse off. I conclude that an account of giving priority to the worse off relevant for healthcare priority setting should take into account how badly off patients are when all of their conditions are considered (holistic severity).     

Community structure in social networks: applications for epidemiological modelling

During an infectious disease outbreak people will often change their behaviour to reduce their risk of infection. Furthermore, in a given population, the level of perceived risk of infection will vary greatly amongst individuals. The difference in perception could be due to a variety of factors including varying levels of information regarding the pathogen, quality of local healthcare, availability of preventative measures, etc. In this work we argue that we can split a social network, representing a population, into interacting communities with varying levels of awareness of the disease. We construct a theoretical population and study which such communities suffer most of the burden of the disease and how their awareness affects the spread of infection. We aim to gain a better understanding of the effects that community-structured networks and variations in awareness, or risk perception, have on the disease dynamics and to promote more community-resolved modelling in epidemiology.     

Seeing the Quiet Politics in Unquiet Woods: A Different Vantage Point for a Future Forest Agenda

Human Ecology - We address two aspects of forest lives—violence and care—that are central to forest outcomes but often invisible in mainstream discussions on forests. We argue that...     

Implementation challenges and opportunities for improved mass treatment uptake for lymphatic filariasis elimination: Perceptions and experiences of community drug distributors of coastal Kenya

Community drug distributors (CDDs) who are volunteers have the responsibility of awareness creation, household census, drug distribution and record-keeping and are thus key stakeholders in the campaign for Lymphatic Filariasis (LF) elimination. Taking into account their experiences and perceptions is important for a successful elimination campaign. We conducted a qualitative study in 2018 to identify implementation challenges and opportunities for improved mass drug administration (MDA) uptake based on the CDDs perceptions and experiences. Within a larger study that used mixed methods quasi-experimental design, we collected qualitative data from two wards in Kaloleni Sub-County of Kilifi County which was purposively selected owing to its low, 56% and 50.5% treatment coverage in 2015 and 2016 respectively. Focus group discussions (FGDs) (n = 8) and in-depth interviews (IDIs) (n = 8) with CDDs, IDIs (n = 22) with opinion leaders and IDIs (n = 8) with health workers were conducted and the data analyzed by QSR NVIVO version 10 according to thematic areas. The results showed that based on the perceptions and experiences of the CDDs, several challenges: communities’ refusal to take the drugs; absenteeism during MDA; non-adherence to CDDs selection criteria; inadequacy in number of CDDs engaged during the campaign and training provided; insufficiency of drugs issued to CDDs; lack of CDDs supervision and low motivation negatively impact on MDA uptake. Opportunities to address the challenges included: awareness creation on MDA, health education on LF and observation of hygiene during drug administration, increased duration of awareness creation and drug administration, adherence to CDDs selection criteria and putting into consideration the vastness of an area and population density while deploying CDDs. Other opportunities include: improved CDDs training and scheduling; issuing of enough drugs to CDDs to meet the communities’ demand and improved supervision and motivation of CDDs. Addressing the challenges highlighted is an important step of maximizing MDA uptake. The opportunities presented need to be considered by the NTD program personnel, the county health personnel and the community while planning the implementation of MDA campaigns.     

Revegetation of urban green space rewilds soil microbiotas with implications for human health and urban design

Many noncommunicable diseases are linked to degraded diversity in the human and environmental microbiota and are rising globally in epidemic proportions in industrialized urban populations. Reducing this disease burden may be aided by the ecological restoration of microbiota and their habitat in urban green spaces—a process termed microbiome rewilding. Microbiome rewilding could serve as a mechanism to increase urban exposure to biodiversity; biodiversity could introduce microbiota species or functional diversity to improve immune training and regulation in urban populations. As a first step in examining this hypothesis, we explored the microbial diversity and composition of a variety of urban green space vegetation types relative to urban revegetated woodlands of varying levels of vegetation diversity, including lawns, vacant lots, parklands, and remnant woodlands. We generated amplicon sequence variant community profiles from bacterial and archaeal 16S rRNA, fungal ITS1 region, and eukaryotic 18S rRNA marker genes. We also made trophic‐mode predictions of the fungal amplicon sequence variants. Across sites, soil microbiotas in revegetated urban green spaces were similar to remnant woodland microbiotas and differed greatly from lawns and vacant lots. There were several differentially abundant genera likely driving these differences that had strong correlations to plant species richness, soil pH, and conductivity. We provide the first evidence, as far as we know, that revegetation can improve urban soil microbiota diversity toward a more natural, biodiverse state by creating more wild habitat conditions. This evidence supports initiating further studies within the growing field of microbiome rewilding.     

Current Knowledge and Practices of Heath Care Professionals on Opioid-Induced Adrenal Insufficiency

Objective: Opioid-induced adrenal insufficiency (OIAI) is reported in up to 29% of chronic opioid users through suppression of the hypothalamus-pituitary-adrenal axis. Unrecognized adrenal insufficiency leads to increased morbidity and potentially death; thus, healthcare provider (HCP) awareness of OIAI is crucial. The aim of the present study was to assess the knowledge and current practices of HCPs regarding OIAI and to identify factors associated with decreased awareness.Methods: We carried out a cross-sectional, anonymous survey of HCPs in internal medicine specialties that prescribe or care for patients taking chronic opioids.Results: Of 91 (30%) participants who completed the survey, 51 (56%) were men and 52 (57%) were in training. Most responders were general internal medicine providers (n = 33, 36%), followed by endocrinologists (n = 13, 14%) and various other specialties (n = 45, 49%). While 61 (67%) of respondents prescribed opioids, only 17 (19%) were comfortable in their knowledge of opioid side effects. Among nonendocrine providers, 53 (68%) identified adrenal insufficiency as a known opioid-induced endocrinopathy. Compared to other providers, endocrinologists were more likely to recognize opioid-related endocrinopathies (69% versus 24%, P = .01) and to identify the correct symptoms for OIAI (38% versus 9%, P <.001). One in four nonendocrine providers reported discomfort in managing glucocorticoid replacement therapy. The majority (60%) of providers indicated that online resources and continuing medical education lectures would improve knowledge of OIAI.Conclusion: Our study identified several deficiencies in HCP knowledge of opioid-induced endocrine effects, especially in nonendocrine providers. As many symptoms of OIAI overlap with those of underlying conditions, OIAI could be potentially missed, highlighting the need to further educate providers about opioid-induced endocrinopathies.Abbreviations: ACTH = adrenocorticotropic hormone; AI = adrenal insufficiency; CME = continuing medical education; HCP = healthcare professional; OIAI = opioid-induced adrenal insufficiency     

Comparison Of Hba1C Goals Proposed By An Algorithm To Those Set By Different Members Of Healthcare Teams Within The Dartmouth Hitchcock Health System

Objective: An individualized approach is recommended by guidelines when establishing hemoglobin A1c (HbA1c) goals. Setting a goal requires experience and awareness; it is time consuming and not always trivial. A previous study proposed an algorithm for assessing the recommended HbA1c target according to individual patient characteristics. Few investigations have explored the variation of HbA1c goals recommended among different types of providers.Methods: We conducted a survey regarding practice settings, practices related to diabetes mellitus type 2, and HbA1c targets recommended to patients. Our objective was to compare HbA1c goals between Dartmouth Hitchcock Healthcare System providers (including endocrinology department, general internal medicine, and family medicine providers) and a previously validated algorithm. The clinical cases presented were those used in the previously published study.Results: The survey was sent to 228 healthcare providers of whom 81 (35.5%) responded. As recommended by the guidelines, healthcare providers individualize their patients' glycemic goals. The glycemic goals proposed by the providers in our institution were similar to those proposed by the international diabetologists and by the algorithm.Conclusion: Our results further validate the proposed algorithm within a heterogeneous population of healthcare providers. The algorithm could help establish glycemic goals and assist healthcare systems in providing more standardized care.Abbreviations: ADA = American Diabetes Association; APRN = advanced practice registered nurse; DH = Dartmouth Hitchcock Healthcare System; FM = family medicine; GIM = general internal medicine; HbA1c = hemoglobin A1c; PA-C = certified physician assistant     

研究型医院研究生培养的几点想法

研究型医院是指以完成临床医疗工作为基本任务,以培养优秀人才为突出优势,以创新性科学研究为重要使命,以制定和修定临床医学标准和规范为水平标志的大型综合型医院。其是我国医院管理界的新生事物。要走研究型医院快速、持续发展之路,提高医院的整体诊治水平,就必须大力培育复合型人才。研究生培养作为研究型医院优秀人才培养的重要组成部分,在培养过程中必然需要新的培养方式。建立与研究型医院发展相适应的研究生培养机制,诱导研究生国际视野,培养研究生创新意识,激发研究生求知欲望,训练研究生专项特长,树立研究生转化医学思维,才能培养出适应研究型医院发展需要的研究生。本文就研究型医院研究生培养的几点想法与同行共享。