RESUMO
Os conteúdos deste livro são uma tradução de sete artigos originais que compuseram a série sobre a abordagem GRADE-CERQual, publicados em 2018 no periódico Implementation Science, volume 13 (Suppl. 1). Esta série de artigos teve como objetivo fornecer orientações sobre como aplicar a abordagem GRADE-CERQual, levando o leitor a conhecer todas as etapas envolvidas na avaliação da con ança nos resultados das sínteses das evidências qualitativas, incluindo os conceitos relacionados com cada componente do CERQual e como esses componentes se reportam a outros conceitos nos campos da pesquisa qualitativa primária e da evidência qualitativa
Assuntos
Humanos , Pesquisa Qualitativa , Avaliação de Programas e Instrumentos de PesquisaRESUMO
O interesse em como fortalecer o uso de evidências de pesquisa em processos de tomada de decisão teve um rápido crescimento em muitos cenários. A formulação de políticas informadas por evidências tornou-se amplamente institucionalizada no setor da saúde e também vem sendo implementada em muitas outras áreas de política social. A evidência qualitativa - dados empíricos extraídos de pesquisa que utiliza métodos qualitativos de coleta e análise de dados - pode desempenhar um papel crítico na formulação de políticas informadas por evidências porque esse tipo de evidência pode capturar as opiniões e as experiências daqueles afetados por uma intervenção ou opção.
Assuntos
Humanos , Tomada de Decisões , Pesquisa Qualitativa , Política Informada por EvidênciasRESUMO
Este livro, decorrente da parceria entre o Instituto de Saúde, a Fiocruz Brasília e o grupo de trabalho GRADE-CERQual, integra os esforços para promover as evidências qualitativas como subsídio relevante para a tomada de decisão em sistemas de saúde, e foi lançado durante o Simpósio Using qualitative evidence to inform decisions in the SDG era: new frontiers and innovations'QESymposium. Os conteúdos deste livro são uma tradução de sete artigos originais que compuseram a série sobre a abordagem GRADE-CERQual, publicados em 2018 no periódico Implementation Science, volume 13 (Suppl.1).
Assuntos
Humanos , Sistemas de Saúde , Pesquisa Qualitativa , Avaliação de Políticas de Pesquisa , Política Informada por EvidênciasRESUMO
BACKGROUND: Governance arrangements include changes in rules or processes that determine authority and accountability for health policies, organisations, commercial products and health professionals, as well as the involvement of stakeholders in decision-making. Changes in governance arrangements can affect health and related goals in numerous ways, generally through changes in authority, accountability, openness, participation and coherence. A broad overview of the findings of systematic reviews can help policymakers, their technical support staff and other stakeholders to identify strategies for addressing problems and improving the governance of their health systems. OBJECTIVES: To provide an overview of the available evidence from up-to-date systematic reviews about the effects of governance arrangements for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on governance arrangements and informing refinements of the framework for governance arrangements outlined in the overview. METHODS: We searched Health Systems Evidence in November 2010 and PDQ Evidence up to 17 December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of governance arrangements on patient outcomes (health and health behaviours), the quality or utilisation of healthcare services, resource use (health expenditures, healthcare provider costs, out-of-pocket payments, cost-effectiveness), healthcare provider outcomes (such as sick leave), or social outcomes (such as poverty, employment) and that were published after April 2005. We excluded reviews with limitations that were important enough to compromise the reliability of the findings of the review. Two overview authors independently screened reviews, extracted data and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence) and assessments of the relevance of findings to low-income countries. MAIN RESULTS: We identified 7272 systematic reviews and included 21 of them in this overview (19 primary reviews and 2 supplementary reviews). We focus here on the results of the 19 primary reviews, one of which had important methodological limitations. The other 18 were reliable (with only minor limitations).We grouped the governance arrangements addressed in the reviews into five categories: authority and accountability for health policies (three reviews); authority and accountability for organisations (two reviews); authority and accountability for commercial products (three reviews); authority and accountability for health professionals (seven reviews); and stakeholder involvement (four reviews).Overall, we found desirable effects for the following interventions on at least one outcome, with moderate- or high-certainty evidence and no moderate- or high-certainty evidence of undesirable effects. Decision-making about what is covered by health insurance- Placing restrictions on the medicines reimbursed by health insurance systems probably decreases the use of and spending on these medicines (moderate-certainty evidence). Stakeholder participation in policy and organisational decisions- Participatory learning and action groups for women probably improve newborn survival (moderate-certainty evidence).- Consumer involvement in preparing patient information probably improves the quality of the information and patient knowledge (moderate-certainty evidence). Disclosing performance information to patients and the public- Disclosing performance data on hospital quality to the public probably encourages hospitals to implement quality improvement activities (moderate-certainty evidence).- Disclosing performance data on individual healthcare providers to the public probably leads people to select providers that have better quality ratings (moderate-certainty evidence). AUTHORS' CONCLUSIONS: Investigators have evaluated a wide range of governance arrangements that are relevant for low-income countries using sound systematic review methods. These strategies have been targeted at different levels in health systems, and studies have assessed a range of outcomes. Moderate-certainty evidence shows desirable effects (with no undesirable effects) for some interventions. However, there are important gaps in the availability of systematic reviews and primary studies for the all of the main categories of governance arrangements.
Assuntos
Governança Clínica/organização & administração , Países em Desenvolvimento , Política de Saúde , Programas Nacionais de Saúde/organização & administração , Governança Clínica/legislação & jurisprudência , Participação da Comunidade , Revelação , Pessoal de Saúde/normas , Programas Nacionais de Saúde/legislação & jurisprudência , Avaliação das Necessidades , Política Organizacional , Literatura de Revisão como AssuntoRESUMO
BACKGROUND: Allowing a broader range of trained health workers to deliver services can be an important way of improving access to safe abortion care. However, the expansion of health worker roles may be challenging to implement. This study aimed to explore factors influencing the implementation of role expansion strategies for non-physician providers to include the delivery of abortion care. METHODS: We conducted a multi-country case study synthesis in Bangladesh, Ethiopia, Nepal, South Africa and Uruguay, where the roles of non-physician providers have been formally expanded to include the provision of abortion care. We searched for documentation from each country related to non-physician providers, abortion care services and role expansion through general internet searches, Google Scholar and PubMed, and gathered feedback from 12 key informants. We carried out a thematic analysis of the data, drawing on categories from the SURE Framework of factors affecting the implementation of policy options. RESULTS: Several factors appeared to affect the successful implementation of including non-physician providers to provide abortion care services. These included health workers' knowledge about abortion legislation and services; and health workers' willingness to provide abortion care. Health workers' willingness appeared to be influenced by their personal views about abortion, the method of abortion and stage of pregnancy and their perceptions of their professional roles. While managers' and co-workers' attitudes towards the use of non-physician providers varied, the synthesis suggests that female clients focused less on the type of health worker and more on factors such as trust, privacy, cost, and closeness to home. Health systems factors also played a role, including workloads and incentives, training, supervision and support, supplies, referral systems, and monitoring and evaluation. Strategies used, with varying success, to address some of these issues in the study countries included values clarification workshops, health worker rotation, access to emotional support for health workers, the incorporation of abortion care services into pre-service curricula, and in-service training strategies. CONCLUSIONS: To increase the likelihood of success for role expansion strategies in the area of safe abortion, programme planners must consider how to ensure motivation, support and reasonable working conditions for affected health workers.
Assuntos
Aborto Induzido , Pessoal de Saúde , Acessibilidade aos Serviços de Saúde/organização & administração , Papel Profissional , Aborto Legal , Atitude do Pessoal de Saúde , Bangladesh , Competência Clínica , Etiópia , Feminino , Pessoal de Saúde/educação , Pessoal de Saúde/psicologia , Humanos , Nepal , Estudos de Casos Organizacionais , Segurança do Paciente , Gravidez , Papel Profissional/psicologia , África do Sul , UruguaiRESUMO
BACKGROUND: A key function of health systems is implementing interventions to improve health, but coverage of essential health interventions remains low in low-income countries. Implementing interventions can be challenging, particularly if it entails complex changes in clinical routines; in collaborative patterns among different healthcare providers and disciplines; in the behaviour of providers, patients or other stakeholders; or in the organisation of care. Decision-makers may use a range of strategies to implement health interventions, and these choices should be based on evidence of the strategies' effectiveness. OBJECTIVES: To provide an overview of the available evidence from up-to-date systematic reviews about the effects of implementation strategies for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on alternative implementation strategies and informing refinements of the framework for implementation strategies presented in the overview. METHODS: We searched Health Systems Evidence in November 2010 and PDQ-Evidence up to December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of implementation strategies on professional practice and patient outcomes and that were published after April 2005. We excluded reviews with limitations important enough to compromise the reliability of the review findings. Two overview authors independently screened reviews, extracted data and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence) and assessments of the relevance of findings to low-income countries. MAIN RESULTS: We identified 7272 systematic reviews and included 39 of them in this overview. An additional four reviews provided supplementary information. Of the 39 reviews, 32 had only minor limitations and 7 had important methodological limitations. Most studies in the reviews were from high-income countries. There were no studies from low-income countries in eight reviews.Implementation strategies addressed in the reviews were grouped into four categories - strategies targeting:1. healthcare organisations (e.g. strategies to change organisational culture; 1 review);2. healthcare workers by type of intervention (e.g. printed educational materials; 14 reviews);3. healthcare workers to address a specific problem (e.g. unnecessary antibiotic prescription; 9 reviews);4. healthcare recipients (e.g. medication adherence; 15 reviews).Overall, we found the following interventions to have desirable effects on at least one outcome with moderate- or high-certainty evidence and no moderate- or high-certainty evidence of undesirable effects.1.Strategies targeted at healthcare workers: educational meetings, nutrition training of health workers, educational outreach, practice facilitation, local opinion leaders, audit and feedback, and tailored interventions.2.Strategies targeted at healthcare workers for specific types of problems: training healthcare workers to be more patient-centred in clinical consultations, use of birth kits, strategies such as clinician education and patient education to reduce antibiotic prescribing in ambulatory care settings, and in-service neonatal emergency care training.3. Strategies targeted at healthcare recipients: mass media interventions to increase uptake of HIV testing; intensive self-management and adherence, intensive disease management programmes to improve health literacy; behavioural interventions and mobile phone text messages for adherence to antiretroviral therapy; a one time incentive to start or continue tuberculosis prophylaxis; default reminders for patients being treated for active tuberculosis; use of sectioned polythene bags for adherence to malaria medication; community-based health education, and reminders and recall strategies to increase vaccination uptake; interventions to increase uptake of cervical screening (invitations, education, counselling, access to health promotion nurse and intensive recruitment); health insurance information and application support. AUTHORS' CONCLUSIONS: Reliable systematic reviews have evaluated a wide range of strategies for implementing evidence-based interventions in low-income countries. Most of the available evidence is focused on strategies targeted at healthcare workers and healthcare recipients and relates to process-based outcomes. Evidence of the effects of strategies targeting healthcare organisations is scarce.