5 de març 2020

What Works to Prevent Violence Against Women and Girls (VAWG)

Violence against women and girls (VAWG) is preventable.

Over the last two decades, the global community has come to recognise the profound impact of violence on the lives of women and girls. This fundamentally undermines their health and well-being, and stands as a barrier to women’s full participation in global development and the economic and civic life of their communities.

What works to prevent violence published last january 2020 a brief where evaluated the design and implementation of diferent interventions designed to reduce VAWG. The interventions were included in four different groups:
  • Community activism approaches to shift harmful gender attitudes, roles and social norms
  • Combined gender transformation and economic empowerment interventions
  • Couples’ interventions and special populations
  • Prevention of violence among and against children
The brief show many examples of well-designed, well-implemented interventions of different modalities. Ten core elements of the design and implementations have contributed to their success.

Eight elements related to the design of the interventions:
  1. Rigorously planned, with a robust theory of change, rooted in knowledge of local context.
  2. Address multiple drivers of VAW, such as gender inequity, poverty, poor communication and marital conflict
  3. Especially in highly patriarchal contexts, work with women and men, and where relevant, families.
  4. Based on theories of gender and social empowerment that view behaviour change as a collective rather than solely individual process, and foster positive interpersonal relations and gender equity
  5. Use group-based participatory learning methods, for adults and children, that emphasise empowerment, critical reflection, communication and conflict resolution skills building.
  6. Age-appropriate design for children with a longer time for learning and an engaging pedagogy such as sport and play
  7. Carefully designed, user-friendly manuals and materials supporting all intervention components to accomplish their goals.
  8. Integrate support for survivors of violence.
Two elements related to the implementation of the interventions:
  1. Optimal intensity: duration and frequency of sessions and overall programme length enables time for reflection and experiential learning
  2. Staff and volunteers are selected for their gender equitable attitudes and non-violence behaviour, and are thoroughly trained, supervised and supported.
What Works to Prevent Violence Against Women and Girls is an innovative global programme working in 13 countries across the world building the evidence base on What Works to prevent violence in low-middle income settings.

Access article (pdf) 2020 What works brief

photo: Vivian Maier (1980)

12 de gen. 2020

clinical practice guidelines and the voice of patients

Clinical practice guidelines (CPG) are the user manuals of modern medicine. If the human body can suffer it, chances are there's a guideline for treating it, from burns and breaks to cancers and strokes. At their best, they provide gold-standard guidance to doctors: how to diagnose and treat a condition, what symptoms to watch for, what tests to order. But that's not always the reality. Clinicians are experts, but the patients with the disease are also experts. They're the ones living with it on a daily basis.

Guideline development could be unsatisfactory and unreliable. Because it so often fails to engage any patients or caregivers. Usually guidelines are developed without any input from the people who would actually experience them. Also, there is no consensus on what exactly patients and their representatives should be asked to do during CPG development. For example, should they be active members of guideline groups, or should patient input and preferences be shared only with clinicians in guideline groups. Moreover, there is little clarity about how guidelines should reflect patient-based evidence, or information generated by patients about different aspects of care, patient preferences, and care experience.

Rand (2019) in an interdisciplinary team of researchers, patient representatives from the Parent Project Muscular Dystrophy (PPMD) and clinicians developed the RAND/PPMD Patient-Centeredness Method (RPM) - a version of a Delphi method- with a online approach to engaging patients and their representatives in Clinicial Practice Guildelines.

The authors said that Duchenne was a good test case, because the disease is so rare, so complex, and the balance between treatment and quality of life is so precarious. but this method should be formally validated and tested in the context of other clinical conditions and compared to other ways of engaging patients in CPG development.

Open access article

photo: Moda ald carrer 1971. Joana Biarnés (1935-2018)

10 de nov. 2019

poverty and health

Michaela Benzeval et al. published in 2014 in The Joseph Rowntree Foundation the report How does money influence health?

The study explores the association between income and health throughout the life course and within families. Researchers reviewed theories from 272 wide-ranging papers, most of which examined the complex interactions between people’s income and their health throughout their lives.

The research identifies four main ways money affects people’s wellbeing:
  1. Material: Money buys goods and services that improve health. The more money families have, the better the goods they can buy.
  2. Psychosocial: Managing on a low income is stressful. Comparing oneself to others and feeling at the bottom of the social ladder can be distressing, which can lead to biochemical changes in the body, eventually causing ill health.
  3. Behavioural: For various reasons, people on low incomes are more likely to adopt unhealthy behaviours – smoking and drinking, for example – while those on higher incomes are more able to afford healthier lifestyles.
  4. Reverse causation (poor health leads to low income): Health may affect income by preventing people from taking paid employment. Childhood health may also affect educational outcomes, limiting job opportunities and potential earnings.
These pathways are all likely to be important and interact across people’s lives in a complex web of links between income and health. The broader context is also important. Living on a low income in a country with a well-developed welfare state is unlikely to have the same health-damaging effects as living in one with poorer provision for healthcare and education.

Given this complexity of interconnection between people’s income and health, a broad approach to improving the health of those with limited resources is important.
Acces full report

photo: Toni Catany

2 d’oct. 2019

healthcare organisations struggling to improve quality

Identifying characteristics associated with struggling healthcare organisations may help inform improvement.
The article published in BMJ Quality and Safety in july 2018 is a systematic reveiw of qualitative studies that evaluated organisational characteristics of healthcare organisations that were struggling as defined "by below-average performance in patient outcomes (eg, mortality) or quality of care metrics (eg, Patient Safety Indicators)".
33 articles from multiple countries and settings (eg, acute care, outpatient) with a diverse range of interviewees (eg, nurses, leadership, staff) were included in the final analysis.

Five domains characterised struggling healthcare organisations: 
  1. Poor organisational culture (limited ownership, not collaborative, hierarchical, with disconnected leadership), 
  2. Inadequate infrastructure (limited quality improvement, staffing, information technology or resources), 
  3. Lack of a cohesive mission (mission conflicts with other missions, is externally motivated, poorly defined or promotes mediocrity), 
  4. System shocks (ie, events such as leadership turnover, new electronic health record system or organisational scandals that detract from daily operations), 
  5. Dysfunctional external relations with other hospitals, stakeholders, or governing bodies.
Many characteristics shared by struggling organisations were counter to characteristics associated with high-performing organisations. For example, while disconnected leaders and non-collaborative environments were frequently found in struggling organisations, engaged leadership and a collaborative organisational culture are associated with high performance. Furthermore, a ‘flat’ or team-based approach to problems is often associated with high performance, whereas they found hierarchical culture in struggling organisations.

System shocks’ was a domain unique to struggling organisations. Although not all change necessarily causes disruption, being unprepared or unrealistic about the effort required can demotivate and anger staff. To prevent disastrous consequences, shocks must be anticipated and addressed. When shocks cannot be anticipated, leaders may directly address shocks to reduce negative consequences and potentially create positive change.

The study has important implications. The findings suggest that health systems preparing for large-scale organisational change should adequately prepare in order to prevent system shocks, which, counterintuitively, may impede change. Also the study underscores the importance of context, organisational climate and related factors in determining hospital performance. 

photographer: Leopoldo Pomés (1931-2019). Foto Colectània 

5 d’ag. 2019

a good place to work

It’s not uncommon to hear people assert that it’s a bad idea to promote an engineer to lead other engineers, or an editor to lead other editors. A good manager doesn’t need technical expertise, this argument goes, but rather, a mix of qualities like charisma, organizational skills, and emotional intelligence.

Andrew Oswald, Benjamin Artz and Amanda Goodall published some articles about how workers are affected by their boss’s technical competence.

They found that employees are far happier when they are led by people with deep expertise in the core activity of the business. These results support the claim that both competence – linked to expert knowledge – and industry experience improve workers’ job satisfaction.

Access to the articles (pdf)
Another interesting articles and a video:
Have a nice summer.

photo: 1925 Life

10 de juny 2019

The CEOs in the NHS

Katharina Janke, Carol Propper* and Raffaella Sadum published in may 2019 a working paper where they investigate whether top managers affect the performance of large public sector organizations. The study examined CEOs of English public hospitals, which are large, complex organizations with multi-million turnover. They studied the impact of individual CEOs on a wide set of measures of hospital performance, intermediate operational outcomes and inputs.

Findings: "There is little evidence that individual CEOs have an impact on a large set of measures of hospital performance".

There are some possible explanations for their findings.
  • The first is public sector-specific. The public sector nature of the NHS wich distort the effort of ther NHS CEOs to pursuit of political targets rather than performance-enhacing policies. The NHS is central in political discourse in the UK. Its importance means that politicians are very concerned about NHS performance, particularly negative performance, and are also keen to be seen to be doing something, which is generally manifest in a desire to implement new policies. The lack of persistent CEO effects is consistent with a scenario in which top managers simply chase political goals, rather than policies that might actually improve hospital performance. In this context, the rational response of a NHS CEO is not necessarily to improve the long-term performance of the hospital but, instead, to minimizethe amount of bad news that ends up on the Secretary of State’s desk. 
  • A second explanation is that hospitals are large complex organizations, in which highly trained (and hard to monitor) individuals run separate but interconnected production processes. Management at the very top of such organizations may find it difficult to engage in coordination and getting a large number of actors, who traditionally have not worked together, to work cooperatively. The organizational inertia of a large hospital is too strong for a single manager – even if this person is the CEO – to be able to impact performance within the short time period in which they are in office, and consistently across organizations. This situation, of course, is not specific to public sector hospitals. But it may have more of an effect in hospitals, public or private, where there are many dimensions of performance (clinical, access, financial) that can be pursued and can in the short run conflict. This inertia may also be exacerbated by the often much longer contract durations of clinical staff relative to CEOs.
  • The short tenure of CEOS (around 3.5 years) in the NHS may dampen their ability to systematically impress their mark in the organization they lead. A leading NHS manager recently argued that it takes five years for a CEO to make a difference but the average time in post is much shorter than that.
  • The management capabilities of middle managers inhospitals are systematically associated with better outcomes. The authors suggest that rather than seeking to rapidly change hospital performance through the appointment of a cadre of “superheads”, strategies for improvement should instead focus on nurturing and sustaining the skills of middle managers.

Paper: CEOs-NHS working paper (2019, pdf)

*Carol Propper will be next friday the 14th in the plenary session of the XXIX Jornadas de Economía de la Salud  presenting this study

photo: Anna de Jaume Plensa, Monestir de Montserrat 2019  Jordi Soldevila