SUNScholar - Browsing by Author "Lewin, Simon"

Browsing by Author "Lewin, Simon"

Now showing 1 - 10 of 10

Delivery arrangements for health systems in low-income countries : an overview of systematic reviews
(John Wiley & Sons, Ltd. on behalf of The Cochrane Collaboration, 2017) Ciapponi, Agustin; Lewin, Simon; Herrera, Cristian A.; Opiyo, Newton; Pantoja, Tomas; Paulsen, Elizabeth; Rada, Gabriel; Wiysonge, Charles S.; Bastias, Gabriel; Dudley, Lilian; Flottorp, Signe; Gagnon, Marie-Pierre; Marti, Sebastian Garcia; Glenton, Claire; Okwundu, Charles I.; Penaloza, Blanca; Suleman, Fatima; Oxman, Andrew D.
Background: Delivery arrangements include changes in who receives care and when, who provides care, the working conditions of those who provide care, coordination of care amongst different providers, where care is provided, the use of information and communication technology to deliver care, and quality and safety systems. How services are delivered can have impacts on the effectiveness, efficiency and equity of health systems. This broad overview of the findings of systematic reviews can help policymakers and other stakeholders identify strategies for addressing problems and improve the delivery of services. Objectives: To provide an overview of the available evidence from up‐to‐date systematic reviews about the effects of delivery arrangements for health systems in low‐income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on delivery arrangements and informing refinements of the framework for delivery arrangements outlined in the review. 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 delivery arrangements on patient outcomes (health and health behaviours), the quality or utilisation of healthcare services, resource use, healthcare provider outcomes (such as sick leave), or social outcomes (such as poverty or employment) and that were published after April 2005. We excluded reviews with limitations important enough to compromise the reliability of the 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 51 of them in this overview. We judged 6 of the 51 reviews to have important methodological limitations and the other 45 to have only minor limitations. We grouped delivery arrangements into eight categories. Some reviews provided more than one comparison and were in more than one category. Across these categories, the following intervention were effective; that is, they have desirable effects on at least one outcome with moderate‐ or high‐certainty evidence and no moderate‐ or high‐certainty evidence of undesirable effects.
Economic support to improve tuberculosis treatment outcomes in South Africa : a pragmatic cluster-randomized controlled trial
(BioMed Central, 2013-05) Lutge, Elizabeth; Lewin, Simon; Volmink, Jimmy; Friedman, Irwin; Lombard, Carl
Abstract Poverty undermines adherence to tuberculosis treatment. Economic support may both encourage and enable patients to complete treatment. In South Africa, which carries a high burden of tuberculosis, such support may improve the currently poor outcomes of patients on tuberculosis treatment. The aim of this study was to test the feasibility and effectiveness of delivering economic support to patients with pulmonary tuberculosis in a high-burden province of South Africa. Methods This was a pragmatic, unblinded, two-arm cluster-randomized controlled trial, where 20 public sector clinics acted as clusters. Patients with pulmonary tuberculosis in intervention clinics (n = 2,107) were offered a monthly voucher of ZAR120.00 (approximately US$15) until the completion of their treatment. Vouchers were redeemed at local shops for foodstuffs. Patients in control clinics (n = 1,984) received usual tuberculosis care. Results Intention to treat analysis showed a small but non-significant improvement in treatment success rates in intervention clinics (intervention 76.2%; control 70.7%; risk difference 5.6% (95% confidence interval: -1.2%, 12.3%), P = 0.107). Low fidelity to the intervention meant that 36.2% of eligible patients did not receive a voucher at all, 32.3% received a voucher for between one and three months and 31.5% received a voucher for four to eight months of treatment. There was a strong dose–response relationship between frequency of receipt of the voucher and treatment success (P <0.001). Conclusions Our pragmatic trial has shown that, in the real world setting of public sector clinics in South Africa, economic support to patients with tuberculosis does not significantly improve outcomes on treatment. However, the low fidelity to the delivery of our voucher meant that a third of eligible patients did not receive it. Among patients in intervention clinics who received the voucher at least once, treatment success rates were significantly improved. Further operational research is needed to explore how best to ensure the consistent and appropriate delivery of such support to those eligible to receive it. Trial registration Current Controlled Trials ISRCTN50689131
Economic support to improve tuberculosis treatment outcomes in South Africa : a qualitative process evaluation of a cluster randomized controlled trial
(BioMed Central, 2014-06) Lutge, Elizabeth; Lewin, Simon; Volmink, Jimmy
Background Poverty undermines the adherence of patients to tuberculosis treatment. A pragmatic cluster randomized controlled trial was conducted to investigate the extent to which economic support in the form of a voucher would improve patients’ adherence to treatment, and their treatment outcomes. Although the trial showed a modest improvement in the treatment success rates of the intervention group, this was not statistically significant, due in part to the low fidelity to the trial intervention. A qualitative process evaluation, conducted in the final few months of the trial, explained some of the factors that contributed to this low fidelity. Methods In-depth interviews were conducted with patients who received vouchers, nurses in intervention clinics, personnel in shops who administered the vouchers, and managers of the TB Control Programme. These interviews were analyzed thematically. Results The low fidelity to the trial intervention can be explained by two main factors. The first was nurses’ tendency to ‘ration’ the vouchers, only giving them to the most needy of eligible patients and leaving out those eligible patients whom they felt were financially more comfortable. The second was logistical issues related to the administration of the voucher as vouchers were not always available for patients on their appointed clinic dates, necessitating further visits to the clinics which they were not always able to make. Conclusions This process evaluation identifies some of the most important factors that contributed to the results of this pragmatic trial. It highlights the value of process evaluations as tools to explain the results of randomized trials and emphasizes the importance of implementers as ‘street level bureaucrats’ who may profoundly affect the way an intervention is administered. Trial registration Current Controlled Trials ISRCTN50689131, registered 21 April 2009.The trial protocol is available at the following web address: http://www.hst.org.za/publications/study-protocol-economic-incentives-improving-clinical-outcomes-patients-tb-south-africa.
Financial arrangements for health systems in low-income countries : an overview of systematic reviews
(John Wiley & Sons, Ltd. on behalf of The Cochrane Collaboration, 2017) Wiysonge, Charles S.; Paulsen, Elizabeth; Lewin, Simon; Ciapponi, Agustin; Herrera, Cristian A.; Opiyo, Newton; Pantoja, Tomas; Rada, Gabriel; Oxman, Andrew D.
Background: One target of the Sustainable Development Goals is to achieve "universal health coverage, including financial risk protection, access to quality essential health‐care services and access to safe, effective, quality and affordable essential medicines and vaccines for all". A fundamental concern of governments in striving for this goal is how to finance such a health system. This concern is very relevant for low‐income countries. Objectives: To provide an overview of the evidence from up‐to‐date systematic reviews about the effects of financial arrangements for health systems in low‐income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on financial arrangements, and informing refinements in the framework for financial arrangements presented 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 financial arrangements on patient outcomes (health and health behaviours), the quality or utilisation of healthcare services, resource use, healthcare provider outcomes (such as sick leave), or social outcomes (such as poverty, employment, or financial burden of patients, e.g. out‐of‐pocket payment, catastrophic disease expenditure) and that were published after April 2005. We excluded reviews with limitations important enough to compromise the reliability of the 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 reviews and included 15 in this overview, on: collection of funds (2 reviews), insurance schemes (1 review), purchasing of services (1 review), recipient incentives (6 reviews), and provider incentives (5 reviews). The reviews were published between 2008 and 2015; focused on 13 subcategories; and reported results from 276 studies: 115 (42%) randomised trials, 11 (4%) non‐randomised trials, 23 (8%) controlled before‐after studies, 51 (19%) interrupted time series, 9 (3%) repeated measures, and 67 (24%) other non‐randomised studies. Forty‐three per cent (119/276) of the studies included in the reviews took place in low‐ and middle‐income countries.
Governance arrangements for health systems in low-income countries : an overview of systematic reviews
(John Wiley & Sons, Ltd. on behalf of The Cochrane Collaboration, 2017) Herrera, Cristian A.; Lewin, Simon; Paulsen, Elizabeth; Ciapponi, Agustin; Opiyo, Newton; Pantoja, Tomas; Rada, Gabriel; Wiysonge, Charles S.; Bastias, Gabriel; Marti, Sebastian Garcia; Okwundu, Charles I.; Penaloza, Blanca; Oxman, Andrew D.
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.
Implementation strategies for health systems in low-income countries : an overview of systematic reviews
(John Wiley & Sons, Ltd. on behalf of The Cochrane Collaboration, 2017) Pantoja, Tomas; Opiyo, Newton; Lewin, Simon; Paulsen, Elizabeth; Ciapponi, Agustin; Wiysonge, Charles S.; Herrera, Cristian A.; Rada, Gabriel; Penaloza, Blanca; Dudley, Lilian; Gagnon, Marie-Pierre; Marti, Sebastian Garcia; Oxman, Andrew D.
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.
Multiple and mixed methods in formative evaluation : is more better? reflections from a South African study
(BioMed Central, 2016) Odendaal, Willem; Atkins, Salla; Lewin, Simon
ENGLISH SUMMARY : Background: Formative programme evaluations assess intervention implementation processes, and are seen widely as a way of unlocking the 'black box' of any programme in order to explore and understand why a programme functions as it does. However, few critical assessments of the methods used in such evaluations are available, and there are especially few that reflect on how well the evaluation achieved its objectives. This paper describes a formative evaluation of a community-based lay health worker programme for TB and HIV/AIDS clients across three low-income communities in South Africa. It assesses each of the methods used in relation to the evaluation objectives, and offers suggestions on ways of optimising the use of multiple, mixed-methods within formative evaluations of complex health system interventions. Methods: The evaluation's qualitative methods comprised interviews, focus groups, observations and diary keeping. Quantitative methods included a time-and-motion study of the lay health workers' scope of practice and a client survey. The authors conceptualised and conducted the evaluation, and through iterative discussions, assessed the methods used and their results. Results: Overall, the evaluation highlighted programme issues and insights beyond the reach of traditional single methods evaluations. The strengths of the multiple, mixed-methods in this evaluation included a detailed description and nuanced understanding of the programme and its implementation, and triangulation of the perspectives and experiences of clients, lay health workers, and programme managers. However, the use of multiple methods needs to be carefully planned and implemented as this approach can overstretch the logistic and analytic resources of an evaluation. Conclusions: For complex interventions, formative evaluation designs including multiple qualitative and quantitative methods hold distinct advantages over single method evaluations. However, their value is not in the number of methods used, but in how each method matches the evaluation questions and the scientific integrity with which the methods are selected and implementented.
The provision of TB and HIV/AIDS treatment support by lay health workers in South Africa : a time-and-motion study
(BioMed Central, 2014-04) Odendaal, Willem A.; Lewin, Simon
Background Lay or community health workers (LHWs) are an important human resource in primary health care, and contribute to improving access to care. However, optimal use of LHWs within the health system is often hampered by a poor understanding of how this cadre organizes its work. This study aimed to better understand how LHWs organize and structure their time in providing treatment and adherence support to people on TB treatment and/or antiretroviral therapy (ART) in South Africa. Methods Fourteen LHWs participated across three low-income peri-urban communities in Cape Town. Each LHW was observed by a researcher for one day, and data collected on each activity and the time spent on it. Data were summarized in the following categories: travel to the patient’s home, waiting time and patient contact time. Results Ninety-seven attempted visits to patients were observed, and patients were located in 69 of these. On average, LHWs conducted six visits per day, each lasting an average of nine minutes. Forty-six percent of the observed time was spent with patients, with the balance spent on ‘non-contact’ activities, including walking to and waiting for patients. The average walking time between patients was 8 minutes (range: 3 to 15 minutes). Activities during visits comprised medical care (that is ensuring that medication was being taken correctly and that patients were not experiencing side-effects) and social support. Other tasks included conducting home assessments to determine risks to treatment adherence, and tracing patients who had defaulted from treatment. Conclusions Because of their tasks and working environment, LHWs providing support to people on TB treatment and ART in South Africa spend a substantial proportion of their time on ‘non-contact’ activities. Programme managers need to take this into account when developing job descriptions and determining patient case-loads for this cadre. More research is also needed to explore whether these findings apply to other tasks and settings. Strategies should be explored to mitigate the challenges that LHWs experience in locating and supporting patients, including the use of new technologies, such as mobile phones.
Researching complex interventions in health : the state of the art
(BMC Health Services Research, 2016) Craig, Peter; Rahm-Hallberg, Ingalill; Britten, Nicky; Borglin, Gunilla; Meyer, Gabriele; Kopke, Sascha; Noyes, Jane; Chandler, Jackie; Levati, Sara; Sales, Anne; Thabane, Lehana; Giangregorio, Lora; Feeley, Nancy; Cossette, Sylvie; Taylor, Rod; Hill, Jacqueline; Richards, David A.; Kuyken, Willem; von Essen, Louise; Williams, Andrew; Hemming, Karla; Lilford, Richard; Girling, Alan; Taljaard, Monica; Dimairo, Munyaradzi; Petticrew, Mark; Baird, Janis; Moore, Graham; Odendaal, Willem; Atkins, Salla; Lutge, Elizabeth; Leon, Natalie; Lewin, Simon; Payne, Katherine; Van Achterberg, Theo; Sermeus, Walter; Pitt, Martin; Monks, Thomas
ENGLISH SUMMARY : Keynote presentations
Task shifting and integration of HIV care into primary care in South Africa : the development and content of the streamlining tasks and roles to expand treatment and care for HIV (STRETCH) intervention
(BioMed Central, 2011-08-02) Uebel, Kerry E.; Fairall, Lara R.; van Rensburg, Dingie H. C. J.; Mollentze, Willie F.; Bachmann, Max O.; Lewin, Simon; Zwarenstein, Merrick; Colvin, Christopher J.; Georgeu, Daniella; Mayers, Pat; Faris, Gill M.; Lombard, Carl; Bateman, Eric D.
Abstract Background Task shifting and the integration of human immunodeficiency virus (HIV) care into primary care services have been identified as possible strategies for improving access to antiretroviral treatment (ART). This paper describes the development and content of an intervention involving these two strategies, as part of the Streamlining Tasks and Roles to Expand Treatment and Care for HIV (STRETCH) pragmatic randomised controlled trial. Methods: Developing the intervention The intervention was developed following discussions with senior management, clinicians, and clinic staff. These discussions revealed that the establishment of separate antiretroviral treatment services for HIV had resulted in problems in accessing care due to the large number of patients at ART clinics. The intervention developed therefore combined the shifting from doctors to nurses of prescriptions of antiretrovirals (ARVs) for uncomplicated patients and the stepwise integration of HIV care into primary care services. Results: Components of the intervention The intervention consisted of regulatory changes, training, and guidelines to support nurse ART prescription, local management teams, an implementation toolkit, and a flexible, phased introduction. Nurse supervisors were equipped to train intervention clinic nurses in ART prescription using outreach education and an integrated primary care guideline. Management teams were set up and a STRETCH coordinator was appointed to oversee the implementation process. Discussion Three important processes were used in developing and implementing this intervention: active participation of clinic staff and local and provincial management, educational outreach to train nurses in intervention sites, and an external facilitator to support all stages of the intervention rollout. The STRETCH trial is registered with Current Control Trials ISRCTN46836853.

Browsing by Author "Lewin, Simon"

Results Per Page

Sort Options