RESUMO
QUALITY ISSUE: Quality improvement (QI) is a key strategy for improving diabetes care in low- and middle-income countries (LMICs). This study reports on a diabetes QI project in rural Guatemala whose primary aim was to improve glycemic control of a panel of adult diabetes patients. INITIAL ASSESSMENT: Formative research suggested multiple areas for programmatic improvement in ambulatory diabetes care. CHOICE OF SOLUTION: This project utilized the Model for Improvement and Agile Global Health, our organization's complementary healthcare implementation framework. IMPLEMENTATION: A bundle of improvement activities were implemented at the home, clinic and institutional level. EVALUATION: Control charts of mean hemoglobin A1C (HbA1C) and proportion of patients meeting target HbA1C showed improvement as special cause variation was identified 3 months after the intervention began. Control charts for secondary process measures offered insights into the value of different components of the intervention. Intensity of home-based diabetes education emerged as an important driver of panel glycemic control. LESSONS LEARNED: Diabetes QI work is feasible in resource-limited settings in LMICs and can improve glycemic control. Statistical process control charts are a promising methodology for use with panels or registries of diabetes patients.
Assuntos
Diabetes Mellitus Tipo 2/prevenção & controle , Educação de Pacientes como Assunto/métodos , Melhoria de Qualidade/organização & administração , Adulto , Idoso , Gerenciamento Clínico , Família , Feminino , Hemoglobinas Glicadas/análise , Guatemala , Visita Domiciliar , Humanos , Indígenas Centro-Americanos , Masculino , Adesão à Medicação , Pessoa de Meia-IdadeRESUMO
An 8.8-magnitude earthquake occurred off the coast of Chile on 27 February 2010, displacing nearly 2,000 children aged less than five years to emergency housing camps. Nine months later, this study assessed the needs of 140 displaced 0-5-year-old children in six domains: caregiver stability and protection; health; housing; nutrition; psychosocial situation; and stimulation. Multivariate regression was applied to examine the degree to which emotional, physical, and social needs were associated with baseline characteristics and exposure to the earthquake, to stressful events, and to ongoing risks in the proximal post-earthquake context. In each domain, 20 per cent or fewer children had unmet needs. Of all children in the sample, 20 per cent had unmet needs in multiple domains. Children's emotional, physical, and social needs were associated with ongoing exposures amenable to intervention, more than with baseline characteristics or epicentre proximity. Relief efforts should address multiple interrelated domains of child well-being and ongoing risks in post-disaster settings.
Assuntos
Desastres , Terremotos , Jovens em Situação de Rua , Avaliação das Necessidades , Proteção da Criança , Pré-Escolar , Chile , Emoções , Feminino , Jovens em Situação de Rua/psicologia , Jovens em Situação de Rua/estatística & dados numéricos , Humanos , Lactente , Recém-Nascido , Masculino , Socorro em DesastresRESUMO
OBJECTIVE: Chile is considering expanding its system for early childhood development to include 5- to 7-year olds, but it has no consensus about how to identify at-risk children. This study facilitated a process for incorporating local priorities and best practices to choose a child assessment instrument. METHODS: Using the priority-setting method of the Child Health and Nutrition Research Initiative (CHNRI), 21 Chilean experts defined and weighted ideal assessment instrument characteristics; 130 instruments were scored according to how closely they matched experts' ideal definitions. Instruments were ranked by score under different inclusion criteria. RESULTS: Experts weighted instrument quality highest (95 on 1-100 scale), followed by administration site (87), domains assessed (82), cost (80), administrator (76), Spanish version (75), time (75), and prior use in Chile (53). Experts agreed that an ideal instrument (1) would reliably assess language, socioemotional well-being, mental health, and parenting abilities, (2) could be administered at schools or home, and (3) could be administered by teachers or parents. No single instrument matched all Chilean priorities. Three instruments met 11 of 13 priorities (age; quality; administration at school, home, or waiting rooms; assess language and socioemotional domains; administered by teachers, parents, or psychologists; time ≤30 minutes). Including mental health or parenting abilities ranked instruments whose composite scores were 35% lower. CONCLUSION: Decisions about how to assess children at developmental risk should be informed by local context. The CHNRI method provided a useful process that made explicit mutually exclusive priorities, quantified trade-offs of different assessment strategies, and identified 3 of the instruments that best met local needs and priorities.
Assuntos
Desenvolvimento Infantil , Testes Neuropsicológicos , Fatores Etários , Criança , Pré-Escolar , Chile , Deficiências do Desenvolvimento/diagnóstico , Deficiências do Desenvolvimento/psicologia , Humanos , Testes Neuropsicológicos/normas , Reprodutibilidade dos TestesRESUMO
Evaluation designs for social programs are developed assuming minimal or no disruption from external shocks, such as natural disasters. This is because extremely rare shocks may not make it worthwhile to account for them in the design. Among extreme shocks is the 2010 Chile earthquake. Un Buen Comienzo (UBC), an ongoing early childhood program in Chile, was directly affected by the earthquake. This article discusses (a) the factors the UBC team considered for deciding whether to put on hold or continue implementation and data collection for this experimental study; and (b) how the team reached consensus on those decisions. A lesson learned is that the use of an experimental design for UBC insured that the evaluation's internal validity was not compromised by the earthquake's consequences, although cohort comparisons were compromised. Other lessons can be transferred to other contexts where external shocks affect an ongoing experimental or quasi-experimental impact evaluation.
Assuntos
Proteção da Criança/estatística & dados numéricos , Terremotos/estatística & dados numéricos , Socorro em Desastres/estatística & dados numéricos , Adaptação Psicológica , Criança , Pré-Escolar , Chile , Coleta de Dados/métodos , Tomada de Decisões , Humanos , Estresse PsicológicoRESUMO
The earthquake of 2010 in Chile holds important lessons about how a rights-based public health system can guide disaster response to protect vulnerable populations. This article tells the story of Chile Grows With You (Chile Crece Contigo), an intersectoral system created three years before the earthquake for protection of child rights and development, and its role in the disaster response. The creation of Chile Grows With You with an explicit rights-oriented mandate established intersectoral mechanisms, relationships, and common understanding between governmental groups at the national and local levels. After the earthquake, Chile Grows With You organized its activities according to its founding principles: it provided universal access and support for all Chilean children, with special attention and services for those at greatest risk. This tiered approach involved public health and education materials for all children and families; epidemiologic data for local planners about children in their municipalities at-risk before the earthquake; and an instrument developed to assist in the assessment and intervention of children put at risk by the earthquake. This disaster response illustrates how a rights-based framework defined and operationalized in times of stability facilitated organization, prioritization, and sustained action to protect and support children and families in the acute aftermath of the earthquake, despite a change in government from a left-wing to a right-wing president, and into the early recovery period.