Background Little is known about factors affecting implementation of patient safety programmes in low and middle-income countries. The goal of our study was to evaluate the implementation of a patient safety programme for paediatric care in Guatemala. Methods We used a mixed methods design to examine the implementation of a patient safety programme across 11 paediatric units at the Roosevelt Hospital in Guatemala. The safety programme included: (1) tools to measure and foster safety culture, (2) education of patient safety, (3) local leadership engagement, (4) safety event reporting systems, and (5) quality improvement interventions. Key informant staff (n=82) participated in qualitative interviews and quantitative surveys to identify implementation challenges early during programme deployment from May to July 2018, with follow-up focus group discussions in two units 1 year later to identify opportunities for programme modification. Data were analysed using thematic analysis, and integrated using triangulation, complementarity and expansion to identify emerging themes using the Consolidated Framework for Implementation Research. Salience levels were reported according to coding frequency, with valence levels measured to characterise the degree to which each construct impacted implementation. Results We found several facilitators to safety programme implementation, including high staff receptivity, orientation towards patient-centredness and a desire for protocols. Key barriers included competing clinical demands, lack of knowledge about patient safety, limited governance, human factors and poor organisational incentives. Modifications included use of tools for staff recognition, integration of education into error reporting mechanisms and designation of trained champions to lead unit-based safety interventions. Conclusion Implementation of safety programmes in low-resource settings requires recognition of facilitators such as staff receptivity and patient-centredness as well as barriers such as lack of training in patient safety and poor organisational incentives. Embedding an implementation analysis during programme deployment allows for programme modification to enhance successful implementation.

Abstract Background Despite Guatemala’s large indigenous population, indigenous health is often neglected in reported health data and interventions. Although this data is limited in scope, it shows that indigenous people have poorer health outcomes. Sexually transmitted infections (STIs) are now a growing threat in Guatemala and pose great risk to the wellbeing of its indigenous population. Methods This qualitative pilot study assessed the knowledge, attitudes, and beliefs of STIs through semi-structured interviews among a previously unstudied population of indigenous Maya women (n = 35, ages 18–50) in the six municipalities of Santa Cruz La Laguna, Guatemala. Results Four key themes were identified: 1) indigenous Maya women have limited factual knowledge about sex and STIs; 2) widespread partner infidelity minimizes women’s control over preventing STI contraction; 3) close-knit communities and the resulting heightened fear of gossip prevents communication and hinders care seeking; and 4) lack of quality medical care and inaccessibility of biomedical healthcare systems pose barriers to seeking care for potential STIs. Conclusions To address these findings, we suggest methods to improve sexual education, combat male infidelity, promote condom use, and improve health services to reduce the incidence of STIs in Maya Guatemala.

Background The implementation of programs to improve patient safety remains challenging in low- and middle-income countries. The goal of our study was to define the barriers and facilitators to implementation of a perioperative patient safety program in Guatemala. Material and methods We conducted semi-structured interviews with 16 staff pre-intervention and a follow-up focus group discussion 1 year later in the perioperative department at the Roosevelt Hospital in Guatemala. We performed qualitative thematic analysis to identify barriers and facilitators to the implementation process, with analysis guided by the Consolidated Framework for Implementation Research. Results We found several dominant themes affecting implementation of a patient safety program. Implementation facilitators included strong prioritization of patient needs, program compatibility with existing workflow, and staff attributes. Barriers included a lack of knowledge about patient safety, limited resources, limited leadership engagement, and lack of formal implementation leaders. Several program modifications were made to enhance successful implementation iteratively during the implementation process. Discussion Our analysis highlights several dominant themes which affect the implementation of a perioperative safety program in Guatemala. Understanding the barriers and facilitators to implementation during program deployment allows for program modification and improvement of the implementation process itself.

Background: Traditional Chinese medicine is widely used for treating aging-related chronic conditions. Therefore, designing a TCM theoretical course for undergraduate nursing students will be a preparation for further clinical practice in TCM in the future. Objectives: To identify the effect of a TCM course designed for undergraduate nursing students on understanding four key parts of TCM theories. Design: A quasi-experimental pre- and post-test study. Setting: A university in China during the 2016 fall semester. Participants: A convenience sample of 47 senior undergraduate nursing students. Methods: Each pair of pre- and post-tests were conducted before and after one lecture. Four pairs pre-/post-tests were conducted during lectures of fundamental theories, TCM diagnostic principles, herb properties, and treatment principles. Four questionnaires including ten multiple-choice questions were used for pre-/post-tests. Stata 14.0 was used for descriptive analysis and paired t-tests. Results: Mean scores of post-tests were significantly higher than those of pre-tests (p < 0.001). Among pre-tests, the lowest correctness rates of key contents in the four lectures were the pathological relation of five elements (31.25%), the differentiation of symptoms for a case analysis (16.67%), the compatibility relation (12.77%), and the role of Monarch herbs (also called as "Principal herbs") and the characteristics of herbal pills (29.79%), separately; the highest were the nature of Yin-Yang (87.50%), identifying symptoms for a specific syndrome (85.42%), the herb usage (95.74%), and the principle of prescription composition (85.11%), separately. TCM knowledge in relation of nature of Yin-Yang and Five Elements and basic principles of TCM knowledge gained more increased correctness rates than that related to pathological-based and differentiation of symptoms. Conclusion: The TCM course has a positive effect to enhance TCM knowledge of undergraduate nursing students. The students were easier to gain TCM fundamental knowledge and principles than pathological based knowledge and differentiation of symptoms.

Utilizing the Framework Method, qualitative research determined the effects of potential barriers to healthcare access faced by 15 self-selected, consenting Indigenous women living in three different communities in the Guatemalan highlands. The women were actively involved in the nutritional recuperation program of the Community Organization, a non-profit clinic. Data collection involved recorded interviews based on a questionnaire designed to ensure culture competency. Responses were grouped into categories based on their relation to potential barriers to healthcare access and were then coded based on impacts on healthcare seeking behaviours. Intercoder reliability was measured and negotiated agreement of results was conducted to reach 100% agreement. Analyses of coded responses compared results between communities and between available sectors of healthcare (folk, public, and non-profit). Inductive reasoning was used to determine the effect of beliefs related to illness on healthcare seeking behaviour. Analyses showed significant differences in the impact of geographical barriers to healthcare access among communities across public and non-profit sectors of healthcare, p < 0.05, and demonstrated categorization of disease states and influence of beliefs related to illness on healthcare seeking behaviour. Results demonstrated a hierarchy of barriers, with barriers such as cost, perceived quality of care, trust of medical provider, and available time only showing a negative effect once the barrier of geography was overcome. Despite the sample bias, these results give insight into factors affecting healthcare seeking behaviours that could contribute to the low utilization of healthcare seen in this population.

Background: Guatemala exhibits the sixth highest rate of child stunting worldwide, and stunting disproportionately affects Guatemala indigenous communities. In a country struggling to combat this result of malnutrition, early child nutrition is especially critical. Specifically, early initiation of breastfeeding is important for the development of newborn infants. Understanding beliefs and practices related to early initiation of breastfeeding in Maya Guatemala may provide an avenue to guide nutrition interventions in indigenous communities. Research aim: This study aimed to determine major beliefs and practices associated with early initiation of breastfeeding among Maya mothers in Lake Atitlán, Guatemala. Methods: As part of a larger study to assess child nutrition in the Lake Atitlán region, we created a series of semistructured interview questions to document breastfeeding practices and beliefs among mothers. We conducted and audio-recorded in-person interviews that were translated from Kaqchikel, the local language, to Spanish by a community assistant. Results: We conducted 178 interviews with mothers; 76% practiced early initiation. Early initiation was associated with the village and complementary feeding practices. Mothers held a variety of beliefs about the value of colostrum, and these beliefs were associated with the village. Mothers who held negative beliefs toward colostrum were more likely to delay breastfeeding initiation. Conclusion: Although most Maya mothers practice early initiation, the intervillage disparity in breastfeeding practices demonstrates a need to geographically focus breastfeeding interventions. Our novel insights into the breastfeeding beliefs among Maya mothers will serve as a guide to structure culturally competent breastfeeding education interventions in indigenous communities.

Although approximately one half of Guatemalans are indigenous, the Guatemalan Maya account for 72% of the extremely poor within the country. While some biomedical services are available in these communities, many Maya utilise traditional medicine as a significant, if not primary, source of health care. While existing medical anthropological research characterises these modes of medicine as medically dichotomous or pluralistic, our research in a Maya community of the Western Highlands, Concepción Huista, builds on previous studies and finds instead a syncretistic, imbricated local health system. We find significant overlap and interpenetration of the biomedical and traditional medical models that are described best as a framework where practitioners in both settings employ elements of the other in order to best meet community needs. By focusing on the practitioner's perspective, we demonstrate that in addition to patients' willingness to seek care across health systems, practitioners converse across seemingly distinct systems via incorporation of certain elements of the 'other'. Interventions to date have not accounted for this imbrication. Guatemalan governmental policies to support local healers have led to little practical change in the health-care landscape of the country. Therefore, understanding this complex imbrication is crucial for interventions and policy changes.

Diabetes is a growing burden in sub-Saharan Africa where traditional medicines (TMs) remain a primary form of healthcare in many settings. In Tanzania, TMs are frequently used to treat non-communicable diseases, yet little is known about TM practices for non-communicable diseases like diabetes.

BACKGROUND:In sub-Saharan Africa, chronic kidney disease (CKD) is being recognized as a non-communicable disease (NCD) with high morbidity and mortality. In countries like Tanzania, people access many sources, including traditional medicines, to meet their healthcare needs for NCDs, but little is known about traditional medicine practices among people with CKD. Therefore, we sought to characterize these practices among community members with CKD in northern Tanzania.METHODS:Between December 2013 and June 2014, we administered a previously-developed survey to a random sample of adult community-members from the Kilimanjaro Region; the survey was designed to measure traditional medicine practices such as types, frequencies, reasons, and modes. Participants were also tested for CKD, diabetes, hypertension, and HIV as part of the CKD-AFRiKA study. To identify traditional medicines used in the local treatment of kidney disease, we reviewed the qualitative sessions which had previously been conducted with key informants.RESULTS:We enrolled 481 adults of whom 57 (11.9 %) had CKD. The prevalence of traditional medicine use among adults with CKD was 70.3 % (95 % CI 50.0-84.9 %), and among those at risk for CKD (n = 147; 30.6 %), it was 49.0 % (95 % CI 33.1-65.0 %). Among adults with CKD, the prevalence of concurrent use of traditional medicine and biomedicine was 33.2 % (11.4-65.6 %). Symptomatic ailments (66.7 %; 95 % CI 17.3-54.3), malaria/febrile illnesses (64.0 %; 95 % CI 44.1-79.9), and chronic diseases (49.6 %; 95 % CI 28.6-70.6) were the most prevalent uses for traditional medicines. We identified five plant-based traditional medicines used for the treatment of kidney disease: Aloe vera, Commifora africana, Cymbopogon citrullus, Persea americana, and Zanthoxylum chalybeum.CONCLUSIONS:The prevalence of traditional medicine use is high among adults with and at risk for CKD in northern Tanzania where they use them for a variety of conditions including other NCDs. Additionally, many of these same people access biomedicine and traditional medicines concurrently. The traditional medicines used for the local treatment of kidney disease have a variety of activities, and people with CKD may be particularly vulnerable to adverse effects. Recognizing these traditional medicine practices will be important in shaping CKD treatment programs and public health policies aimed at addressing CKD.

OBJECTIVESTo measure trauma-related distress and evaluate the feasibility, acceptability, and preliminary efficacy of an 8-week yoga intervention (YI) in reducing trauma-related symptoms and emotional and behavioral difficulties (EBD) among children living in orphanages in Haiti.DESIGNCase comparison with random assignment to YI or aerobic dance control (DC) plus a nonrandomized wait-list control (WLC) group.SETTINGTwo orphanages for children in Haiti.PARTICIPANTS76 children age 7 to 17 years.INTERVENTIONThe YI included yoga postures, breathing exercises, and meditation. The DC group learned a series of dance routines. The WLC group received services as usual in the institutional setting. After completion of data collection, the WLC group received both yoga and dance classes for 8 weeks.OUTCOME MEASURESThe UCLA PTSD Reaction Index and the Strengths and Difficulties Questionnaire were used to indicate trauma-related symptoms and EBD, respectively. A within-subject analysis was conducted to compare pre- and post-treatment scores. A post-treatment yoga experience questionnaire evaluated acceptability of the YI.RESULTSAnalyses of variance revealed a significant effect (F[2,28]=3.30; p=0.05) of the YI on the trauma-related symptom scores. Regression analyses showed that participation in either 8 weeks of yoga or dance classes suggested a reduction in trauma-related symptoms and EBD, although this finding was not statistically significant (p>0.05). Respondents reported satisfaction with the yoga program and improved well-being.CONCLUSIONSChildren with trauma-related distress showed improvements in symptoms after participation in an 8-week yoga program compared to controls. Yoga is a feasible and acceptable activity with self-reported benefits to child mental and physical health. Additional research is needed to further evaluate the effect of yoga to relieve trauma-related distress and promote well-being among children.

Introduction Traditional medicines are an important part of healthcare in sub-Saharan Africa, and building successful disease treatment programs that are sensitive to traditional medicine practices will require an understanding of their current use and roles, including from a biomedical perspective. Therefore, we conducted a mixed-method study in Northern Tanzania in order to characterize the extent of and reasons for the use of traditional medicines among the general population so that we can better inform public health efforts in the region. Methods Between December 2013 and June 2014 in Kilimanjaro, Tanzania, we conducted 5 focus group discussions and 27 in-depth interviews of key informants. The data from these sessions were analyzed using an inductive framework method with cultural insider-outsider coding. From these results, we developed a structured survey designed to test different aspects of traditional medicine use and administered it to a random sample of 655 adults from the community. The results were triangulated to explore converging and diverging themes. Results Most structured survey participants (68%) reported knowing someone who frequently used traditional medicines, and the majority (56%) reported using them themselves in the previous year. The most common uses were for symptomatic ailments (42%), chronic diseases (15%), reproductive problems (11%), and malaria/febrile illnesses (11%). We identified five major determinants for traditional medicine use in Northern Tanzania: biomedical healthcare delivery, credibility of traditional practices, strong cultural identities, individual health status, and disease understanding. Conclusions In order to better formulate effective local disease management programs that are sensitive to TM practices, we described the determinants of TM use. Additionally, we found TM use to be high in Northern Tanzania and that its use is not limited to lower-income areas or rural settings. After symptomatic ailments, chronic diseases were reported as the most common reason for TM use which may be particularly important in Northern Tanzania where non-communicable diseases are a rapidly growing burden.

OBJECTIVESThis study aimed to document clinical use of Traditional Chinese Medicine (TCM) for chronic conditions in all TCM hospitals in a Chinese province and to recommend treatments most in need of evaluation for use in community health centers.DESIGNA cross-sectional survey was conducted in the summer of 2010. It included 119 of 132 TCM hospitals in Hubei Province, China. TCM physicians were asked to recommend specific TCM treatments for common chronic conditions. Nine types of chronic conditions recommended more than 3.7 times (mean of frequencies of chronic conditions) are included in this analysis. Frequency of each TCM treatment and the number of visits by type of chronic conditions were calculated.RESULTSThe total number of recommendations by TCM physicians was 411. For seven types of treatments, six were recommended for musculoskeletal pain, five for soft tissue injuries, four for visceral pain and fractures, three for stroke and asthma, two for hemorrhoids, and one for hypertension. The most frequently recommended treatments for specific conditions include orally ingested herbs for visceral pain (n=3), type 2 diabetes (n=5), and hypertension (n=7); herbs for external use for soft tissue injuries (n=10), asthma (n=6), and hemorrhoids (n=8); acupuncture for musculoskeletal pains (n=43) and for stroke (n=10); and Chinese external fixation for fractures (n=24). The number of visits for recommended treatments per year of was 671,759. The most frequently recommended treatments for specific chronic conditions have most visits, except for chronic conditions such as musculoskeletal pains, visceral pains, soft tissue injuries, and asthma.CONCLUSIONSPatients with musculoskeletal pain have more treatment options than other patients. Herbal medicine is the option most commonly used for chronic conditions. These treatments for these conditions should be targeted for further evaluation of effectiveness and, only if found effective, considered for use in primary care settings.