Kisiizi Hospital Health Insurance scheme started in 1996 to; improve access to health services, and provide a stable source of funding and reduce bad debts to Kisiizi hospital. Objectives of this study were; to describe Kisiizi Hospital Health Insurance scheme and to document lessons learned and implications for universal health coverage.This was a descriptive cross-sectional study. Data from different sources were triangulated and thematically analysed.Most households (96%) were organized in Engozi societies (e-Societies), met monthly, and made financial contributions. Cultural solidarity in e-Societies provided a platform for the Kisiizi hospital health insurance scheme establishment, operation and made it compulsory for members. e-Societies disciplinary measures and fear of high out-of-pocket payment for health care enforced enrolment, retention and increased membership. Community sensitisation and community participation in setting premiums and co-payments provided for better understanding of health insurance and rendered them acceptable, affordable and equitable. Membership increased from 330 in 1996 to 38,400 families in 2017. Kisiizi hospital health insurance scheme covered only health services obtained from Kisiizi hospital. Kisiizi hospital health insurance scheme offered no exemption, credit and referral facilities. e-Societies sometimes paid premiums for members from savings and offered them loans to. Kisiizi hospital provided good quality health services, which were easily accessed by insured members. Kisiizi hospital got a stable source of funding and reduced debt burden.Kisiizi hospital health insurance scheme improved access to health services, provided a stable source of funding and reduced bad debts to the hospital. Internal and external factors to e-Society enforced enrolment and retention of members in Kisiizi hospital health insurance scheme. Good quality health services at Kisiizi hospital demonstrated value for money and offered incentives for enrolment and retention, and coverage expansion. Community sensitization and participation in setting premiums and co-payments rendered Kisiizi hospital health insurance scheme acceptable, affordable and catered for equity. Insured members enjoyed benefits; protection against catastrophic health spending, impoverishment, and easy access to quality health care.The online version of this article (10.1186/s12913-018-3266-8) contains supplementary material, which is available to authorized users. Health insurance has been perceived to enhance access and utilization of good quality health services, and to provide protection against catastrophic health expenditure . EvidencSeveral countries in Sub Saharan Africa have implemented community-based health insurance schemes  in whichHowever, community-based health insurance schemes are characterized by: low coverage; low premiums; lack of trust; poor understanding of insurance; poor quality health services, high operational costs and limited health benefit packages , 9, 10. Kisiizi Hospital Health Insurance scheme is a community-based health insurance scheme owned by Kisiizi hospital, a faith based hospital in South Western Uganda. At the time of the launch (1996), patients sought health care at the Kisiizi hospital when illnesses were in advanced stages. Delays to seek care were mainly due to lack of ready and adequate cash to spend on health care , 12. ThiThe pressure of maintaining good quality health services had compelled the hospital to raise the prices of care to levels beyond which further increase would significantly impede health service utilization by residents in the hospital catchment area. The objectives of Kisiizi Hospital Health Insurance scheme establishment were three fold: to improve access to health services; to provide a stable source of funding for the hospital; and to reduce the problem of bad debts.Most households in villages in the Kisiizi hospital catchment area were organised in Engozi societies (e-Societies). Engozi is a locally made stretcher used to transport patients to hospital and at times to bring back home the dead loved ones for descent burial. A household with a severely sick person sounded a drum in a particular rhythm to invite e-Society members to carry the patient in turns to hospital .e-Society tradition brings people together to address a common problem of rugged land terrain that is unfavourable for motor vehicle ambulance use. In addition, some patients cannot afford the cost of transport by ambulance and resort to this local means.e-Society members were eligible to register in Kisiizi Hospital Health Insurance scheme provided they paid the required premiums and co-payments. Photographs and membership information of all registered members were entered into a computer based system. Eligible members were able to access services two weeks after effecting payments. Premium payment receipts work as membership cards to all family members. The objectives of this study were; to describe Kisiizi Hospital Health Insurance scheme, and to document lessons learned and policy implications.This was a descriptive cross-sectional study where both quantitative and qualitative methods were applied. Three principle investigators collected data in July 2017 through: a review of Kisiizi Hospital Health Insurance Scheme documents to access documented evidence; key informant interviews with three health providers and three chairpersons of e-societies with the aim of collecting information from stakeholders with firsthand knowledge about Kisiizi Hospital Insurance Scheme and its operations using key informant interview guide  in the Kisiizi hospital catchment area were members of e-Societies. They met once every month and made financial and other forms of contributions. Requirements to enrol into Kisiizi Hospital Health Insurance scheme were being a member of e-society, and payment of premium and copayment. Renewal is usually enforced by e-society demands. The hospital finance office adds up the costs of services consumed by members monthly and gives the total expenditure by members to the scheme to reimburse.e-society savings are available for loaning to members to generate income. Sometimes, e-Societies paid premiums for members in Kisiizi Hospital Health Insurance scheme using savings. Solidarity that exists in e-societies provided a platform for implementation and operation of Kisiizi Hospital Health Insurance scheme. Participants in focus group discussions concurred that;“e-Societies reserved funds were made available for borrowing in case of failure to raise money needed to pay premiums and co-payments” .Families who were not members of e-Societies and/or members of Kisiizi Hospital Health Insurance scheme faced severe disciplinary actions when in need of support from e-Societies members. Disciplinary measures included; refusal to transport the patient to the hospital, refusal to transport the dead back home in case the patient died while at the hospital, and refusal to participate in the burial process until a penalty was settled. Penalties were in form of cash or slaughtering a goat of their choice and preparing a banquet for them to feast at the family cost.Membership in the Kisiizi Hospital Health Insurance scheme gradually increased over 21 years as shown in Table Increase in membership was attributed to: continuous sensitization of the communities and increased understanding of the insurance concept and benefits; community participation; fear of e-Society disciplinary measures and high costs of health care; and increased geographical coverage from three sub-counties to seven districts or up to a radius of 60 km from the hospital. Despite the increase in membership, over 235,334 households in the catchment area are still not insured.Kisiizi Hospital Health Insurance scheme was understood as a financing method where households put efforts together and shared the burden of diseases in order to reduce costs of health services to individuals. Participants acknowledged that;“The burden of large sums of money required before the Kisiizi Hospital Health Insurance scheme was no longer a hindrance to insured households. Raising premiums and co-payments was not as strenuous as raising funds to pay full health care costs” [Focus Group Discussion 3]."My brother has been to the hospital three times and he has not sold portions of his land to pay for his health care because of being a member of Kisiizi Hospital Health Insurance scheme" [key informant 1].e-Society leaders registered family members, collected premiums, and submitted a lump sum to the Kisiizi Hospital Health Insurance scheme office. They were given family receipts, which worked as membership cards to all family members.Premiums depended on household size while co-payments are hinged on whether care was provided on an outpatient or inpatient basis as shown in Tables Average exchange rate: 1 US dollar to 3595.90 Uganda shillings .Co-payment covered examination by a clinician, common laboratory investigations and medicines.Kisiizi Hospital Health Insurance did not have specific benefit packages. The premium and copayments catered for any type of health services received except for the excluded services.Kisiizi Hospital Health Insurance scheme paid for healthcare services obtained from Kisiizi Hospital only. Kisiizi Hospital Health Insurance scheme did not cover cost of care obtained from other sources including referred patients. Kisiizi Hospital Health Insurance scheme paid up to US$ 556.2 per person per episode of sickness and remained with a net balance. Kisiizi Hospital Health Insurance scheme had no external donations or did not need to borrow money, and had no patient debts to the hospital.Sources of household income used to pay premiums and co-payments were sale of agricultural products, small retail shops, brick making, wood products and sell of manual labour. Participants in all focus group discussions indicated that all households were able to pay the premiums and co-payments charged Kisiizi Hospital Health Insurance scheme.“Every household was capable of raising funds needed to pay premiums and co-payment required in Kisiizi Hospital Health Insurance scheme. Even the poor who were willing to enroll into the scheme generated required funds generated from sell of manual labour” .All participants revealed that households needed little money for co-payment compared to large sums of money required to obtain health services at Kisiizi hospital when not insured. In one focus group, participants said;“Premiums and co-payments in Kisiizi Hospital Health Insurance scheme were fair and affordable compared to the large sums of money required if not a member of Kisiizi Hospital Health Insurance scheme” [Focus Group Discussion 1].“Sell of manual labour was a more reliable source of income”. The consensus was that every household was capable of raising resources needed to pay for health services provided. The barrier was that households shun the sell of manual labour because of the perceived social stigmatization.Kisiizi hospital provided a wide range of good quality health services for medical and surgical conditions, casualty and emergency services, out-patient services, in- patient services, special investigations including X-ray, Ultrasound, ECG (heart tracing), and laboratory investigations. Key informants from the hospital attributed good quality services to the presence of adequate trained health providers, support staff, logistics and medical supplies. They are all coverage by the Kisiizi Hospital Health Insurance scheme with some exceptions as detailed in the following sections.Services that were covered 100% by Kisiizi Hospital Health Insurance scheme included: outpatient and inpatient medical and surgical conditions; emergency services; investigative procedures such as X-ray, ultrasound, electrocardiogram and laboratory investigations; and in-patient services due to complications of chronic diseases provided evidence of good adherence to treatment guidelines was shown.Services covered 50% by the Kisiizi Hospital Health Insurance scheme were mainly elective surgery such as; prostatectomy, hysterectomy, removal of fibroids, tubal ligation, mastectomy and surgery of the goitre.Services not covered by Kisiizi Hospital Health Insurance scheme included: dentures; spectacles/optical appliances; self-inflicted injuries such as complications of failed suicide attempt, criminal abortion and fights under influence of alcohol and other substance abuse; chronic diseases such as diabetes, high blood pressure, asthma, epilepsy and other mental illnesses; fertility treatment and procedures; food and food supplements; police forms; routine medical checkup for jobs or school; semen analysis; culture and sensitivity; glycated haemoglobin test; international normalized ratio assays evaluating the extrinsic pathway of coagulation; hormonal tests (prostate surface antigen test and thyroid-stimulating hormone blood test); patient referrals and care obtained from outside Kisiizi hospital.There were no exemption and credit facilities for the poor households in Kisiizi Hospital Health Insurance scheme. Inequities were addressed through community participation in setting premiums and co-payments, and in the management of Kisiizi Hospital Health Insurance scheme. e-Society chairpersons and elected executive committee of community representatives on the Kisiizi Hospital Health Insurance scheme management conceded that;“All households were potentially able to pay premiums and co-payments. Inequities did not arise in Kisiizi Hospital Health Insurance scheme” [e-Society Chairpersons and Community representatives].Participants revealed that non-insured household members were simply not willing to pay premiums. They said non-insured households argued that:“premiums were not transferrable across contract periods in case no family member fell sick in one contract period; Kisiizi Hospital Health Insurance scheme did not cater for health care obtained from other sources; and wanted to invest the money for premiums into business and make out-of-pocket payment using interest generated by the trade” [e- Society Chairpersons and Community representatives].Major problems faced were mobilising e-Society member families to subscribe Kisiizi Hospital Health Insurance scheme, bad past experience with insurance companies which never honoured their obligations, and households had not explicitly understood the importance insurance, how it operates and the benefits. Also the belief that households paid taxes and government had a free health care policy discouraged and delayed enrolment and retention in Kisiizi Hospital Health Insurance scheme.Households lacked financial risk protection mechanisms and experienced a high burden of health expenditure, escaped from hospital beds before complete recovery without settling bills, sold assets, and owed the hospital unpaid debts. This was similar to what was observed especially in rural settings in other countries .e-Societies were formed to respond to common problems; difficult transport due to rugged terrain and challenges during burials. Members of e-Societies worked toward measurable goals; they pooled resources and shared health risks. There were unwritten guidelines and code of conduct to ensure a smooth running of e-Societies business; members met monthly on a specified agreed day, made financial and other forms of contributions as need arose. Benefits outweighed transactional costs . This waCultural solidarity in e-Societies was an important tool in the establishment of Kisiizi Hospital Health Insurance scheme while qualities of e-Societies enforced enrolment, retention of membership. Cultural solidarity in e-Societies and their qualities have led to the establishment of many similar health insurance schemes e.g. Ishaka Hospital Insurance scheme, Nyakibale Hospital Health Plan, Kitanga Health insurance scheme, Nyamwegabira Health Insurance scheme . EnrolmeKisiizi hospital should not risk exploiting the solidarity in the e-Societies in order to generate funds for the hospital. This would weaken Kisiizi Hospital Health Insurance scheme’s credibility and even lead it to collapse when it lose trust and attraction among others as evidence suggested .Kisiizi Hospital Health Insurance scheme membership growth was a composite product of community sensitization, increased understanding insurance, appreciation of benefits, e-Society enforcement, sharing of experience between insured and uninsured households, affordable sources of funds for households, and desire to continue accessing quality care at a low cost. Every household could afford to sell non-traditional cash crops and manual labour. In addition, e-Society had a loan facility from which members could acquire credit at affordable interest rate similar to savings and credit schemes , 23. FroStrong community participation was a strength in Kisiizi Hospital Health Insurance scheme. Chairpersons of e-Societies registered households for Kisiizi Hospital Health Insurance scheme, collected premiums from members, and delivered collections to the Kisiizi Hospital Health Insurance scheme office. Elected representatives of the community participated in setting premiums, co-payments and management of Kisiizi Hospital Health Insurance scheme. Community participation enhanced acceptance, enrolment, and retention that in turn increased Kisiizi Hospital Health Insurance scheme membership and generation of funds. Community participation also offered an opportunity to match premiums and co-payments to existing household resources, address house income disparities, reduce inequities and increase access to care as evidence suggested , 25.Although cultural solidarity in e-Societies and Kisiizi Hospital Health Insurance scheme offered an opportunity to tap into household resources, inequities still existed and were a challenge because household had different income levels. Evidence showed the incidence of catastrophic health spending was high in rural settings and out of pocket payments were even higher . FurtherSuccess factors for Kisiizi Hospital Health Insurance scheme were cultural solidarity and enforcement by e-Societies disciplinary measures, resilience, continuous community sensitization and participation in all aspects of Kisiizi Hospital Health Insurance scheme, fear of high costs of health care, and incentive generated availability of good quality health services at Kisiizi hospital. The other success factors included community understanding of insurance and appreciation of benefits of being members of the Kisiizi Hospital Health Insurance scheme; cross learning between insured and non-insured members; protection against catastrophic health expenditure, had peace of mind with no much worries about medical bills or selling household assets, and access to good quality health services.It is still early for Kisiizi Hospital Health Insurance scheme to celebrate any wins. Currently there is no health financing mechanism is an end to itself. Kisiizi Hospital Health Insurance scheme generated additional funding for health but other sources of funding were still needed to buffer the decreased funding especially when membership drops . There wA significant proportion of households were not insured. A bad past experience with insurance companies, which never honoured their obligations made it difficult to mobilise community members to subscribe to Kisiizi Hospital Health Insurance scheme. Others did not understand the importance of health insurance, how it operated and benefits. They did not perceive value for money in Kisiizi Hospital Health Insurance scheme and instead argued they could invest the money in business and pay cash (out of pocket) for health care from interest.Development process of Kisiizi Hospital Health Insurance scheme to date had lasted 21 years but positive progress has been registered. This was a similar experience to what established insurance schemes went through . DevelopUniversal health coverage entails all people should access needed health care without experiencing catastrophic health spending. However, by December 2017, about half of the world’s population and big numbers of households suffered catastrophic health expenditure because of out of pocket payment for health care. Pooling is one of the core functions of health financing because it spreads financial risk across the population so that no individual carries the full burden of paying for health care. It is against this backcloth that the Kisiizi Hospital Health Insurance Scheme makes a contribution towards the achievement of universal health coverage. Lessons learned from Kisiizi Hospital Health Insurance Scheme can be applied to other similar settings with adjustments to meet the specific needs of different societies , 35.Solidarity in e-Societies formed a suitable foundation to begin Kisiizi Hospital Health Insurance scheme. Enforcement by e-Societies contributed significantly to enrolment and retention of membership in Kisiizi Hospital Health Insurance scheme. e-Societies also availed a loan facility to members and sometimes paid premiums for members using savings.Community sensitization increased awareness and created demand for insurance while community participation was one of the strengths of Kisiizi Hospital Health Insurance scheme and promoted confidence and acceptability of Kisiizi Hospital Health Insurance scheme, helped to match premiums household resources, and partly addressed inequities.Motivation to demand Kisiizi Hospital Health Insurance scheme cover was from fear of high costs of care, catastrophic health spending and e-Society disciplinary actions. Sensitization and sharing experiences between insured and non-insured made households appreciate benefits of subscribing to Kisiizi Hospital Health Insurance scheme and realised that they could generate funds for premiums and co-payments from sale of traditional non-cash crops and manual labour.Availability of good quality health services was a matchless incentive and guaranteed insured members of value for their money. Kisiizi Hospital Health Insurance scheme facilitated access to these services which in turn attracted household members to enrol, subscribe and remain members.Members of Kisiizi Hospital Health Insurance scheme enjoyed benefits such as; financial protection, access to good quality health services, and reduced sale of household assets. There was no more need to escape from the hospital bed before complete recovery as it used to happen in the past before Kisiizi Hospital Health Insurance scheme establishment.However, a significant proportion of households were not insured. A bad past experience with insurance companies which never honoured their obligations made it difficult to mobilise community members to subscribe Kisiizi Hospital Health Insurance scheme. Others did not understand the importance of health insurance, how it operated and benefits. They did not perceive value for money in Kisiizi Hospital Health Insurance scheme and instead argued they could invest the money in business and pay out-of-pocket for health care from interest.Kisiizi hospital achieved her objectives to; improve access to health services, and provide a stable source of funding and reduce burden of bad debts. Key findings of this study show that Kisiizi Hospital Health Insurance scheme met the cost of care for members and had a net balance, no debt to the hospital and did not need donations. Kisiizi Hospital Health Insurance scheme was self-reliant and sustainable in the long run.Kisiizi Hospital Health Insurance scheme tapped into cultural solidarity in e-Societies which provided a concrete foundation for it to begin, and enforced enrolment and retention of her members in the scheme. Most ethnic groups have cultures which could be exploited for a similar purpose.Availability of good quality health care was paramount and mandatory to generate confidence, demystify public scepticism and assure value for money. This provided incentives for enrolment, retention, and in Kisiizi Hospital Health Insurance scheme coverage.Relentless community sensitization increased awareness and created demand for Kisiizi Hospital Health Insurance scheme. Community participation in Kisiizi Hospital Health Insurance scheme contributed to making premiums resonate with household resources and expectations of the beneficiaries.Development of a health insurance scheme requires ample time and was not a one time-off process. It took Kisiizi Hospital Health Insurance Scheme 21 years and positive progress has been registered. Some of the established health insurance schemes took over 60 years to reach their current state. Resilience is success factor in the development of health insurance schemes.Community based health insurance schemes similar to Kisiizi Hospital Health Insurance scheme may not be replicated directly in other areas with different cultural complexities. They could be introduced and operated as savings and credit schemes with government capitation, and households make contribution using the local traditions as in the case of e-Societies. However, the net balance should be reserved by scheme and not surrendered to the health provider as it occurs in the case of Kisiizi Hospital Health Insurance scheme.There was potential for government to capitalise similar schemes and operate them as credit and savings schemes. Decreasing membership dues as savings increase, and enable the indigent to join the schemes and enjoy the benefits.There were areas for future research to understand possibility for portability of benefits within an effective referral system, and implementation of similar insurance schemes using Kisiizi Hospital Health Insurance scheme experience in different ethnic groups.There were several success stories to learn from the development process of Kisiizi Hospital Health Insurance scheme that could useful for policy and decision makers. These were as follows;Additional file 1:Qualitative data from key informants. Key informant interview guide facilitated collection of data from three health providers and three chairpersons of e-societies. These were key actors in the Kisiizi Hospital Insurance Scheme with firsthand knowledge about it and its operations, and could provide information that was very useful in this study. (DOCX 15 kb)Additional file 2:Qualitative data from discussions. Group discussion guide facilitated collection of data from a group of twenty community representatives (chairpersons of e-societies) and twenty four selected insured members from the community in three focus group discussions of eight members. This enabled researchers to generate valuable data and insights on Kisiizi Hospital Insurance Scheme from memories, ideas, experiences, perceptions, opinions, and attitudes of stakeholders in an interactive group setting with freedom to talk among group members. (DOCX 16 kb)


Methods: Leading IPC personnel of 297 hospitals with established healthcare-associated infection (HCAI) surveillance provided information on local surveillance and feedback by using a questionnaire. Results: Most hospitals focused on bloodstream infection (BSI) (n = 251) and surgical site infection (SSI) (n = 254), with a SSI post-discharge surveillance in 148 hospitals. As part of the HCAI surveillance, meticillin-resistant Staphylococcus aureus (MRSA) was the leading multidrug-resistant organism (MDRO) under surveillance. Seventy-nine per cent of hospitals (n = 236) monitored alcohol-based hand rub (ABHR) consumption. Feedback to the local IPC committees mainly included outcome data on HCAI  and MDRO among HCAI ; whereupon a feedback of MDRO data depended on hospital size (p = 0.012). Discussion/conclusion: Objectives and methods of surveillance vary across Europe, with BSI, SSI and MRSA receiving considerably more attention than indicators such as pneumonia and urinary tract infection, which may be equally important. In order to maximise prevention and control of HCAI and MDRO in Europe, surveillance should be further improved by targeting relevant HCAI. The role of feedback should be explored in more detail.Hospitals from 24 European countries were asked for information on infection prevention and control (IPC) indicators as part of the Prevention of Hospital Infections by Intervention and Training (PROHIBIT) survey.  Clostridium difficile infection (CDI) accounting for a high proportion in the latter. HCAIs result in increased morbidity and mortality, and emerging antibiotic resistance complicates their treatment. The cumulative burden of HCAIs is higher than the total burden of other communicable diseases in Europe [Based on the results of the first European point prevalence survey (PPS) in 2011–12 an estimated 3.2 million patients acquire a healthcare-associated infection (HCAI) in acute care hospitals in Europe every year [Surveillance as the ‘ongoing systematic collection and analysis of health data for the planning, implementation, and evaluation, of public health practice’  is a keySince the 1990s, many European countries have been developing national surveillance networks, either by applying the United States’ (US) Centers for Disease Control and Prevention (CDC) National Nosocomial Infection Surveillance/National Healthcare Safety Network (NNIS/NHSN) protocol, or by using adapted methods to better take into account local diagnostic practices .Surveillance of alcohol-based hand rub (ABHR) consumption has become a mandatory quality indicator with public reporting in France since 2006 , and wasAspects of specific surveillance activities in European hospitals were obtained as part of the Prevention of Hospital Infections by Intervention and Training (PROHIBIT) project. The PROHIBIT survey was conducted as the first pan-European survey on infection prevention and control (IPC) in order to describe which IPC recommendations are actually being used across Europe and to provide information on gaps in hospitals’ IPC policies and practices for policymakers, hospital managers and healthcare workers for further improvement of HCAI prevention. This article summarises data on findings from 24 European countries.ECDC national contact points (NCPs) and IPC experts of European countries outside of the European Union (EU) were invited to organise national polls. The NCPs invited national hospitals for participation between September 2011 and March 2012. Participation in the PROHIBIT survey was based mainly on hospital interest rather than on a systematic sampling process.The survey was developed by an interdisciplinary group and discussed with the HAI-Net representatives. It included four questionnaires in order to assess IPC structure and process indicators (i) at the hospital level, (ii) in intensive care units (ICU), (iii) in non-ICU medical wards and (iv) in non-ICU surgical wards. Questionnaires addressed organisation and activities of IPC at those various levels.The complete method of the survey and the characteristics of the participating hospitals are described in more detail elsewhere .Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci (VRE), extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae, carbapenem nonsusceptible or carbapenemase-producing Enterobacteriaceae, carbapenem-resistant Pseudomonas aeruginosa and multiresistant Acinetobacter baumannii.For the present analysis, data on HCAI surveillance, process and outcome indicators , direct hand hygiene observations, feedback practices, and persons performing surveillance are described at hospital level. Hospitals were asked whether the following multidrug-resistant organisms (MDRO) were monitored among HCAI: meticillin-resistant Local IPC professionals were also asked to provide data on hospital characteristics such as status (public/private) and size of the hospital (number of beds), and the full time equivalent (FTE) of infection control personnel.Furthermore, country characteristics such as the United Nations (UN) European geographical region, and healthcare expenditure (HCE) as share on the national gross domestic product (GDP) were collected ,16.Descriptive data analysis was performed and results summarised as totals and strata of the following four parameters: hospital size , UN European geographical regions, full-time-equivalent (FTE) infection control nurses (ICN)  per 1,000 acute care hospital beds ≤ / > the median of all participating hospitals  and HCE as share on GDP ,16. HCE Of 32 invited countries, 24 participated  with 309Surveillance in the hospitals mainly focused on SSI and BSI, and less often on PN, CDI and UTI . SurveilSurveillance of CDI was reported most often by hospitals in Northern Europe and more often by hospitals in countries with high HCE; but these differences were not statistically significant. Hip prosthesis implantation (HPRO) was the most common indicator operation of SSI surveillance with higher percentages in countries with high HCE; but these differences were not statistically significant. In 148 of 254 hospitals with SSI surveillance (58%), post-discharge surveillance (PDS) was in place.(n = 243) and VRE (n = 228). Multidrug-resistant Acinetobacter baumannii surveillance was reported by 204 hospitals, carbapenem nonsusceptible or carbapenemase-producing Enterobacteriaceae by 189 hospitals, and carbapenem-resistant Pseudomonas aeruginosa by 185 hospitals.MRSA was the most commonly observed MDRO among HCAI in almost all hospitals (n = 273), followed by ESBL-producing EnterobacteriaceaeConsumption of ABHR and hand hygiene compliance was observed in 79% and 78% of the hospitals, respectively . HospitaIn almost all hospitals, healthcare workers (HCW) received feedback on HCAI . Of the 236 hospitals that performed ABHR consumption surveillance, 200 hospitals provided feedback at least once a year , while in 35 hospitals feedback was given less than once a year and for one hospital information on the frequency of feedback was unavailable. Concerning direct hand hygiene compliance observations, 152 hospitals provided immediate feedback to the observed personnel and 131 hospitals provided a later summary feedback.As shown in the To our knowledge, the data of the PROHIBIT survey offer the first broad analysis of HCAI and MDRO surveillance activities in European acute care hospitals. The findings show that content and methods of surveillance and the role of feedback vary widely across Europe. Hospitals focused more frequently on the surveillance of outcome indicators as BSI and SSI than on PN, CDI or UTI. This may be due to numerous success stories of BSI and SSI preventability, which raised hospitals’ awareness towards these two infection types -19.Fifty-eight per cent of hospitals with SSI surveillance reported to have PDS in place. Such additional surveillance as described by Woelber et al. in 2016, partly prevents under-reporting of SSI in Europe .Nevertheless, successful preventability of HCAIs such as PN and UTI has also been described ,23 and dResources are limited; and thus, priorities must be made in HCAI surveillance, even if a broad surveillance strategy including process and outcome indicators is considered helpful to tailor intervention activities for HCAI prevention. Prospective hospital-wide HCAI surveillance is resource-intensive, and in this sense, it was surprising to find that the proportion of hospitals with hospital-wide PN and UTI surveillance was significantly higher in hospitals from countries with low HCE compared to hospitals from countries with high HCE. Generally, hospital-wide surveillance of HCAI is time-consuming and repeated PPSs on HCAI or an automated surveillance linking administrative data and clinical databases including microbiology may be a better approach.Large healthcare-associated outbreaks of CDI in the first decade of 2000 sparked increased awareness of CDI prevention in Europe, and resulted in European guidelines on CDI prevention in 2008, recommending CDI surveillance . Data ofAlthough low, still 10% of hospitals in Europe, and nearly 20% of hospitals in Eastern Europe, collect HCAI data by ward personnel only. This method of case finding can be interpreted as a more passive rather than active surveillance, with potential bias of under-reporting. As recommended by the Association for Professionals in Infection Control and Epidemiology (APIC), appropriate education to apply infection surveillance definitions or to perform detailed risk factor collection is indispensable .In addition to the surveillance of outcomes, many hospitals assess data on hand hygiene performance indicators. Monitoring process indicators and assessment of adherence to IPC measures such as hand hygiene observation, enables hospitals to identify gaps and improve adherence to IPC measures more promptly than by focusing on outcome data alone. Interestingly, our study identified a discrepancy between a relatively high number of hospitals monitoring ABHR consumption and a relatively low number of hospitals giving feedback on ABHR consumption data to their IPC committees. This may be due the fact that many hospitals start surveillance activities focusing on outcome indicators and still work on the feedback of these indicators rather on reporting ABHR. In addition, ABHR data are often collected yearly, and thus, may be reported less frequently to IPC committees. On the other hand, process indicators are better candidates to be used for a realistic target-setting both at ward and hospital level. Reference data on these indicators facilitate inter-hospital comparison to support improving their processes . Europe-In order to alter their behaviour in HCAI prevention HCWs have to be aware of the problem of HCAI in their setting. Data of our survey indicate that HCWs do receive feedback on HCAI rates in order to raise awareness. However, more research is needed to explore how surveillance data are communicated and perceived, and how this process can be further optimised. Feedback of data may be combined with behaviourally informed approaches such as the setting of long-term goals and encouraging involvement/participation of HCWs for creating local ownership and reflection on achievements and further activities.Since successful implementation of IPC measures requires the participation of HCWs and other stakeholders, feedback to members of the IPC committee is essential. Especially in smaller hospitals, feedback is not always established yet. In which way the size of a hospital influences feedback of MDRO data to hospitals’ stakeholders cannot be fully answered. It can be speculated that larger hospitals see more MDROs, and thus, data are perceived more relevant, particularly because they care more frequently for patients with severe and/or chronic diseases.In the future, all hospitals’ IPC committees should be encouraged to work with MDRO data in order to address supporting organisational factors such as leadership support and communication in MDRO transmission prevention and antibiotic stewardship programmes ,30.The current survey gives insight into established surveillance activities of European hospitals. However, there are some limitations:Participation in the survey was voluntary, and thus, based mainly on hospitals’ interest rather than on a randomised sampling process. Therefore, the data may have overestimated surveillance activities in European hospitals. A randomly selected sample would have improved representation of hospitals in Europe. However, the questionnaire could not have been imposed on hospitals, and thus, data quality and the number of participating hospitals might have been lower.The UN geographical regions are not homogeneous in terms of GDP, healthcare organisation and culture. However, by also reporting data in reference to countries’ HCE, we tried to take into account such heterogeneity.Our findings show that objectives and methods of surveillance vary across Europe. Some outcome indicators, such as BSI, SSI and MRSA, seem to receive considerably more attention than others that are equally important, such as PN, UTI or CDI.Hospitals’ IPC committees mainly receive data on outcome indicators as HCAI and MDRO, but less often on process indicators as hand hygiene performance indicators.In order to better address prevention of HCAI and antimicrobial resistance in Europe surveillance should be further improved by targeting all relevant HCAI and MDRO and providing active surveillance by trained personnel. To what extent surveillance of process indicators prevent HCAI must be further analysed. In addition, the role of feedback and behaviourally informed approaches should be explored in more detail.


Past research has focused on typhoid fever surveillance with little attention to implementation methods or effectiveness of control interventions. This study purposefully sampled key informants working in public health in Chile, India, Pakistan, Bangladesh, Thailand, Vietnam, South Africa, and Nigeria to 1) scope typhoid-relevant interventions implemented between 1990 and 2015 and 2) explore contextual factors perceived to be associated with their implementation, based on the Consolidated Framework for Implementation Research (CFIR). We used a mixed methods design and collected quantitative data (CFIR questionnaire) and qualitative data . Interview data were analyzed using a deductive qualitative content analysis and summary descriptive statistics are provided for the CFIR data. Despite relatively few typhoid-specific interventions reportedly implemented in these countries, interventions for diarrheal disease control and regulations for food safety and food handlers were common. Most countries implemented agricultural and sewage treatment practices, yet few addressed the control of antibiotic medication. Several contextual factors were perceived to have influenced the implementation of typhoid interventions, either as enablers  or barriers . Consolidated Framework for Implementation Research factors rated as important in the implementation of typhoid interventions were remarkably consistent across countries. The findings provide a snapshot of typhoid-relevant interventions implemented over 25 years and highlight factors associated with implementation success from the perspective of a sample of key informants. These findings can inform systematic investigations of the implementation of typhoid control interventions and contribute to a better understanding of the direct effects of implementation efforts. In addition, population-based data on risk factors related to safe water, adequate sanitation, appropriate personal and food hygiene, migration, and vaccination are needed to understand pathways to change with respect to disease burden and to improve priority setting for policies and actions that can prevent and control typhoid fever. Although there is evidence of significant reductions in the disease burden of typhoid across many LMICs, especially in Latin America and Southeast Asia,2 research to date has focused on monitoring typhoid rates with little attention to the implementation of typhoid control interventions. There are no data available on the type of control interventions that have been implemented, nor on the implementation effectiveness of these interventions. Because the distinction between intervention effectiveness (typhoid control outcomes) and implementation effectiveness (whether interventions were well implemented) is important, the relative contributions of control interventions, such as investments in clean water, sanitation and hygiene (WASH) strategies; health and immunization strategies; food safety regulations; or socioeconomic development remain unclear. Also unknown is whether rates of disease over time relate to the success or failure of control interventions or to the implementation approach, or both.3 To this end, the present study purposefully sampled key informants working in public health to explore a range of typhoid-relevant interventions implemented in eight countries: Chile, India, Pakistan, Bangladesh, Thailand, Vietnam, South Africa, and Nigeria.Typhoid fever remains a significant health burden in low- and middle-income countries (LMICs)7 Many implementation barriers appear to be common across countries. For instance, a secondary qualitative analysis of meeting reports and articles describing projects undertaken by Puchalski Ritchie et al.7 in five LMICs on three continents found a high degree of commonality for barriers across countries and clinical areas, with lack of financial, material, and human resources featuring as most prominent. By contrast, few facilitators were identified, and these varied substantially across countries and interventions.Although there is no empirical evidence on the implementation of typhoid control interventions specifically, there is some evidence on the facilitators and barriers to the implementation of other interventions in the context of LMICs, including exclusive breastfeeding, Human papillomavirus vaccinations, antenatal care and maternal health, and others.8We have limited evidence about which implementation strategies are effective for promoting practice change in LMICs and endemic contexts. There is some evidence on the effectiveness of implementation strategies to improve uptake and compliance with evidence-based clinical practice guidelines in LMICs for mental disorders and for other noncommunicable diseases. Existing literature suggests that multifaceted implementation strategies that involve an educational component may be effective for improving guideline adherence and, subsequently, clinical outcomes.8We also know little about effective implementation processes in LMIC contexts. A study of guideline utilization in Uganda revealed that of 137 health sector guidelines, 83 of which were related to Millennium Development Goals, there was no framework for systematic dissemination. More than 60% of guidelines available at the central level were not available at the service delivery level, and there was no framework for systematic monitoring of use, evaluation, and review of guidelines. Also noted was suboptimal supervision that would encourage the use of guidelines, assess their utilization, and provide feedback.9 Implementation models or conceptual frameworks enhance effectiveness of interventions by helping to focus interventions on the essential processes of behavioral change, which can be quite complex. Moreover, the use of theories and frameworks in implementation research enhances interpretability of study findings and ensures that essential implementation strategies are included.10 Although there are a number of guiding models and frameworks for implementation, few comprehensively address the diverse array of factors associated with implementation success. The CFIR organizes these key factors into five domains  of 37 measurable constructs . The contribution of the CFIR is that it allows for the comprehensive examination of a variety of contextual factors that are empirically associated with successful implementation across a variety of disciplines  and that may not have been taken into account in studies using controlled designs that would have “blocked” or ignored them. The Consolidated Framework for Implementation Research also enables examination of specific challenges, barriers, and facilitators identified during implementation and evaluation of programs that have the potential to modify the effect of an intervention. For instance, a study of exclusive breastfeeding implementation in Ethiopia and Mali revealed several contextual factors that were strongly related to improved exclusive breastfeeding rates in both countries4 including adaptation, relative advantage, complexity, needs of the target population, networking, external policies and incentives, tension for change, change agents’ and implementers’ knowledge and attitudes about the intervention, and establishing strong champions for the intervention.The present study was guided by a well-documented implementation framework called the Consolidated Framework for Implementation Research (CFIR).In the present study, we collected quantitative data (CFIR questionnaire) and qualitative data (interviews with key informants) with the aim of exploring and describing 1) the typhoid-relevant interventions implemented between 1990 and 2015 in the aforementioned eight countries and 2) the contextual factors that shaped their implementation. The application of CFIR to interventions well supported by evidence, such as potential typhoid control interventions, allows for the examination of contextual factors perceived to be important for successful implementation of these interventions and ultimately contributes to elucidating which factors are most strongly associated with implementation success. Qualitative interviews were conducted to explore specific typhoid-relevant interventions that were implemented in each of the eight countries. The research was overseen by a global advisory committee comprising global health experts and public health country-level experts with the requisite information and access to data.18 Scoping of typhoid-relevant interventions implemented in these eight countries and contextual implementation factors perceived to be associated with decreasing typhoid rates allows for identification of commonalities and differences for these factors across contexts and has the potential to inform implementation research and practice as well as policy and priority setting about interventions to tackle the global burden of typhoid. Together with the results of our larger quantitative study,18 these findings could facilitate the development of an evidence-based implementation approach for the control of typhoid in LMICs.This implementation study was conducted as a complement to a larger study exploring country-specific data sets for rates of disease burden over time.This study was approved by the Research Ethics Board at The Hospital for Sick Children, Toronto, Canada, and by our counterparts in the study countries, where required. Except in Chile, all participants indicated in writing their consent to participate in the present research; in Chile, participants consented verbally.20 combined qualitative data from interviews with key informants who were purposefully selected public health experts, and quantitative data from a CFIR questionnaire.21 Data were collected simultaneously with the purpose of seeking complementarity; the “elaboration, enhancement, illustration, and clarification of the results from one method with the results from the other method.”20A mixed methods designN = 12), clinician scientist (N = 8), laboratory scientist (N = 7), researcher (N = 3), professor (N = 2), and veterinarian (N = 2). Demographic characteristics for participants in each country are summarized in Participants included 34 public health experts  from eight countries: Chile, India, Pakistan, Bangladesh, Thailand, Vietnam, South Africa, and Nigeria. Participants were identified in each country by the study leads based on their expertise and lifelong careers dedicated to public health (Mean work experience = 29.0 years and SD = 10.3 years). Participants’ roles included advisor or director of health/public health/disease control  was followed in each country to explore a predetermined set of typhoid-relevant interventions and factors . At the same time, informants were also invited to discuss additional interventions or contextual factors they believed to be relevant for their country. The interview protocol was developed based on our conceptual framework2 and literature review.Qualitative data consisted of semi-structured interviews with key informants. With the exception of South Africa, where data were collected via phone interviews, interviews were conducted in person, audio-taped, and transcribed verbatim. With the exception of Chile, all interviews were conducted in English. In Chile, interviews were conducted by local researchers in Spanish, audio-recorded and subsequently translated to English locally. Interviewer training for Bangladesh, Chile, India, and Pakistan involved reviewing the interview tool and was conducted over the telephone. The remaining four countries’  interviews were conducted by Dr. Raluca Barac, a qualitative scientist in our team at The Hospital for Sick Children. The same interview protocol (see 22 was used to document specific aspects of the implementation of typhoid-relevant interventions related to intervention characteristics (eight items), inner (12 items) and outer settings (four items), process (eight items), and staff characteristics (five items) for a total of 37 questions. Items were rated on a 5-point Likert scale (1 “very unimportant” and 5 “very important”).Quantitative data were collected with a CFIR questionnaire which was administered in person by the interviewer following each interview. The CFIR questionnaire, developed by the authors (M.B. and R.B.) for an earlier study,23 such as the implementation of typhoid-relevant interventions in Asia, Africa, and South America. Specifically, analyses mapped onto the two main aims of the present study exploring and describing 1) country-specific typhoid-relevant interventions implemented between 1990 and 2015 and 2) contextual factors perceived to have shaped their implementation.Interview data were analyzed using a deductive qualitative content analysis approach, appropriate for exploring and describing lesser known phenomena23 We used a deductive approach where codes were determined a priori, based on the CFIR conceptual framework, and data coded against seven large categories of interventions and factors: public health campaigns and vaccinations for typhoid, diarrheal disease control, food safety, food handlers, agricultural practices, treatment of sewage, and antibiotics. Data were analyzed by four authors  working in pairs to ensure that all transcripts were double-coded to achieve qualitative rigor. Data were categorized under the seven predetermined typhoid-relevant interventions, although we remained open to new intervention types that might emerge from the data. Team members worked independently and met regularly to review coding, discuss differences, and make decisions to ensure coding consistency.Content analysis refers to a set of strategies used to analyze textual data in which data are coded and categorized to describe the content and identify common issues, trends, and facts.Analysis of quantitative data from the CFIR questionnaire was limited by small sample size. As such, summary descriptive statistics are provided for all CFIR domains and constructs to provide a picture of their relative importance.Results are presented to reflect the two main aims of the study: 1) describing the typhoid-relevant interventions implemented in the eight countries and 2) exploring the contextual factors associated with their implementation.This figure summarizes the seven categories of interventions that may have had an effect on the trends in typhoid in Bangladesh, Chile, India, Nigeria, Pakistan, South Africa, Thailand, and Vietnam. Within each of the seven categories, specific interventions are listed, and the presence or absence of these interventions are recorded for each country.Typhoid-specific interventions typically occurred in response to local typhoid outbreaks and included vaccination campaigns; public education regarding the causes, treatment, and prevention of typhoid fever; and physician education to improve diagnosis and treatment. In Vietnam, for instance, typhoid fever outbreaks in the Mekong River Delta in the early 1990s triggered vaccination programs in the area and public education about proper handwashing techniques and boiling water before consumption. Typhoid-relevant interventions in Pakistan were implemented in response to emergency situations, such as the earthquake in 2005 and floods in 2010, and focused on vaccinations for children younger than 5 years living in the affected areas and public education on clean water and sanitation. Typhoid control in South Africa was similar, such that local typhoid outbreaks stimulated improvements in water systems, vaccination campaigns, and fever screening for migrants at the borders. Not all countries reportedly implemented interventions specifically targeting typhoid fever .Interventions for diarrheal disease control were implemented in all countries through a variety of activities, including public health campaigns for handwashing; building, improving, or expanding the safe water infrastructure; and building toilets. In Thailand, efforts to expand the pipe water system across the country spanned 30 years (1970s to 2000) and latrine construction occurred over four decades, ending in the 2000s. Community health volunteers played a key role in these initiatives and communities who accomplished the task were recognized with a golden latrine or jar symbol. In Nigeria, handwashing campaigns promoting the slogan “your life is your hands” intensified in response to the country’s 2014 Ebola epidemic. Messages about handwashing and drinking clean water were disseminated via multiple communication channels, including talks given at schools, market places, churches, and mosques; jingles on the radio; announcements in schools; advertisements in markets and bus stops; and participation in the Global Hand Washing Day. Although fear of Ebola was a strong motivator for behavior change and placed control measures as a high priority for the country, Nigeria’s promotion of handwashing and drinking safe water predates this crisis and has more longstanding history, as illustrated by a large school campaign implemented in 2008 that reached 1.5 million children and a United Nations Children’s Fund-led campaign that provided motorized borehole pumps as early as 2000. In South Africa, typhoid outbreaks in 2000s were commonly traced back to water contamination that triggered significant investments in improving access to safe water and sanitation and public education.All eight countries implemented interventions to regulate food safety. Public education interventions on food safety took place in four countries , whereas interventions to regulate the quality of street and restaurant food were conducted in Chile, Nigeria, Pakistan, South Africa, Thailand, and Vietnam . In response to the first cholera cases in the 1990s, Chile introduced a public education campaign for cooked food and banned restaurants from serving raw foods. Thailand implemented multiple food safety interventions from 1990 to 2015, beginning with a “National Salmonella Control Program.” In addition, a “Biocontainment Program” worked to ensure that food produced in Thailand met European Union food safety standards for export. The “Farm to Table” and “Clean Food, Good Taste” campaigns targeted food quality and safety by ensuring that restaurants met certain criteria to receive the “Clean Food, Good Taste” certificate and by educating the public to only eat at restaurants with this certification. In Nigeria, mandatory regulation coupled with consistent inspections and fines ensure that market stalls are cleaned every Thursday before market opening.Not all food safety interventions have been implemented effectively. Efforts to ban street food in metropolitan regions in India failed, but more recent initiatives aimed at improving food standards and food labeling have been more successful. Similarly, in Vietnam and South Africa, regulations for food storage, washing, and preparation are in place, but follow-up to ensure effective implementation and adherence are variable, with large differences emerging between rural and urban areas. Inconsistent follow-up and inspection of food safety standards is also an issue for Pakistan.Salmonella Typhi. Measures to ensure implementation and adherence of food handler regulations occur variably across the study countries and are fraught with adherence issues. Vietnam conducts random checks on food handlers, and Nigeria, Thailand, and Vietnam promote gloves for food handlers. All interviewees noted that limited surveillance was a barrier to the successful implementation of food handler regulations.Regulations related to food handlers varied among study countries. In India and Bangladesh, interventions targeting food handlers focused on food safety education. The other six countries implemented mandatory vaccinations and/or tests to check carrier status for disease. Thailand has implemented European Union regulations in food factories, including biannual mandatory health checks for workers in chicken factories and annually for workers in seafood factories. Similarly, food handlers diagnosed with typhoid fever in South Africa are required to stop working until three consecutive stool samples are found to be free of Interviewees from India and Bangladesh noted there are no specific measures in place to regulate agricultural practices related to typhoid control. By comparison, Chile, Nigeria, Pakistan, and Vietnam commonly provide farmer education with a focus on safe irrigation of crops and discontinuing the practice of using wastewater for this purpose. In Thailand, similar measures preventing the use of wastewater for irrigation have been in place before 1990s. The use of wastewater for irrigation and tests of water quality were also implemented in South Africa. Chile has had a strong emphasis on the regulation of agricultural practices from 1990 to 2015, driven by the identification of the first cases of cholera in early 1990s. Although the use of wastewater for crop irrigation was banned by a decree passed in 1967, the implementation of these regulations only began in the 1980s and was only drastically enforced in the 1990s to control the spread of cholera. Several behavior change strategies were implemented, including fines for farmers who used wastewater for irrigation, destruction of crops that showed contamination or were irrigated with wastewater, mandatory building of wells for irrigation, mandatory testing of the irrigation water, education of students in agriculture and related programs regarding water contamination and safe irrigation, and sanitary barriers preventing the contaminated crops from being spread to the whole country.With the exception of Bangladesh, where interviewees were unaware of any specific sewage treatment interventions implemented between 1990 and 2015, the remaining seven countries noted progress in the last 25 years, most notably with the construction of treatment plants for sewage , establishing incentives for improving sewage treatment quality and sanctions on industrial, urban, or hospital waste , improving the waste disposal infrastructure (Pakistan), cleaning up major rivers (India), and continuing the implementation of older regulations for treatment sewage (Thailand).Most of the study countries undertook few, if any, measures to control the sale and use of antibiotic medication, although all interviewees noted the issue of rising rates for antimicrobial resistance. The exception is South Africa, as the sale of antibiotics here is strictly controlled. Some countries made efforts to educate physicians regarding antimicrobial resistance (Pakistan) or to initiate public education campaigns regarding the risks of taking antibiotics without prescription , to regulate antibiotic use in hospitals, and conduct random pharmacy audits by the Ministry of Health (Vietnam). In Thailand, most of the antibiotics are sold over the counter with controls for only select few.This figure presents the typhoid-relevant interventions that interview participants in each case country deemed most effective, denoted by a checkmark and least effective denoted in the figure by an “x” in the control of typhoid fever.Interviewees from six of the eight countries noted vaccination campaigns as the least effective intervention because of low cost-effectiveness, negative side effects (particularly for the earlier vaccine versions), low awareness in the population regarding the existence of typhoid vaccines, and the general belief that vaccines alone could not control typhoid in the absence of additional interventions, such as WASH. Antibiotic control campaigns (Nigeria), treatment of wastewater (India), and food safety regulations (Vietnam) were also perceived as ineffective in controlling typhoid, mainly for reasons related to poor implementation.In addition, qualitative analyses highlighted several contextual factors perceived to have influenced the implementation of typhoid-relevant interventions as enablers  or barriers  see . Most ba24 called the CFIR.25 The study findings provide a snapshot of typhoid-relevant interventions implemented over 25 years and the factors considered to be associated with implementation success from the perspective of a small sample of key informants working in public health in these endemic countries. These findings have the potential to inform future systematic investigations of the implementation of typhoid control interventions and LMIC health evidence implementation more broadly  and contribute to a better understanding of how such implementation efforts impact typhoid rates.Past research has focused on the monitoring of typhoid rates with little attention to implementation methods or effectiveness of typhoid control interventions. To address this gap, the present study purposefully sampled key informants working in public health to explore a range of typhoid-relevant interventions implemented in eight countries: Chile, India, Pakistan, Bangladesh, Thailand, Vietnam, South Africa, and Nigeria. Our aims were to scope 1) the typhoid-relevant interventions implemented in these countries between 1990 and 2015 and 2) the contextual factors perceived to be associated with their implementation, based on a determinant implementation model26 Within certain contexts, the capacity to perform culture tests to confirm infectious pathogens is not present either because of a lack of trained personnel or diagnostic tools.26 In other settings, available tests fall short of the gold standard.26 For example, Widal tests are used in resource-limited environments; however, it lacks the necessary sensitivity and specificity to accurately diagnose typhoid and paratyphoid fever.27 This can lead to overestimation of the incidence of typhoid, and in turn, inappropriate prescription of antibiotics.28 An assessment of multidrug-resistant (MDR) S. Typhi strains, characterized as being resistant to ampicillin, chloramphenicol, and co-trimoxazole, noted that MDR has been on the rise since the 1980s.29 A study conducted in Cameroon, reviewed how medical professionals were interpreting Widal tests and assigning treatment to patients.28 This study found that within their sample, 84% of nurses and just less than 50% of doctors had difficulty identifying those who did not need treatment, which in turn led them to prescribe treatment that was unnecessary.28 The over prescription of antibiotics has played a key role in the increasing burden of drug and MDR strains of S. Typhi being observed in sub-Saharan Africa and South Asia and remains a major public health concern.28Overall, with the exception of South Africa, relatively few typhoid-specific interventions and measures to control the use of antibiotic medication were reportedly implemented in these eight countries. A concern in the lack of control surrounding antibiotic use lies in the diagnosis of typhoid fever and the resultant increase in antibiotic resistance. The availability and quality of diagnostic tests for infectious diseases vary widely in LMICs.However, most of the study countries implemented agricultural and sewage treatment practices and all study countries implemented interventions for diarrheal disease control and regulations for food safety and food handlers. The relationship between outbreaks and carrier interventions was not specifically captured, but it was noted in five countries  that carrier status testing was performed in food handlers. Vietnam was the only country where respondents confirmed the testing of food handlers for typhoid carriage occurred at the national level, the level of implementation in the remaining four countries was unspecified . Interve27 Implementation outcomes are the effects of deliberate and purposive actions to implement new treatments, practices, and services, and they have three important functions: 1) they serve as indicators of the implementation success, 2) they are proximal indicators of implementation processes, and 3) they are key intermediate outcomes30 in relation to service system or clinical outcomes in treatment effectiveness and quality-of-care research. Implementation outcomes serve as necessary preconditions for attaining desired changes in health, clinical, or service outcomes because interventions cannot be effective if they are poorly implemented.3These data provide a descriptive snapshot of the strategies implemented for typhoid control across the eight countries over a period of 25 years and suggests future implementation directions. What remains unknown are the specific implementation and facilitation methods that were followed to implement these strategies and whether typhoid control interventions were implemented with high compliance and/or fidelity. In other words, we have no indication of implementation outcomes as distinct from service system outcomes and clinical treatment outcomes.Analyses of contextual factors that are important for implementation success highlighted several factors associated with implementation success across the eight countries: Intervention Characteristics, including 1) the evidence strength and quality of the health intervention, 2) its adaptability, and 3) its relative advantage over other health interventions; Outer Setting Characteristics such as 1) the population needs and resources and 2) external policies and incentives; Key Inner Setting Characteristics included 1) the presence of organizational incentives and rewards and 2) available resources; Staff Characteristics perceived as associated with effective implementation of typhoid controls included 1) staff with solid knowledge and beliefs about the intervention and 2) a sense of self-efficacy; Process Characteristics identified as important included 1) planning for change, 2) engaging key people in the implementation, 3) the presence of formal implementation leaders, and 4) the opportunity to evaluate and reflect on the implementation process and outcomes.32 Taken together, these studies highlight a subset of CFIR contextual factors identified by key informants as more highly associated with implementation effectiveness. Knowing which factors are more “important” relative to effective implementation has implications for advancing implementation knowledge and practice in global health, such that factors that emerge as highly associated with success can be taken into account in implementation planning, monitoring, and evaluation.These findings are remarkably consistent with past research that has explored CFIR contextual factors associated with implementation success in different sectors  and settings (LMICs).7 . In addition, interviewees in most of the study countries discussed the importance of implementation quality and adherence to the interventions implemented, noting that the adoption of evidence-based interventions was necessary but insufficient without comparative effort in the monitoring of implementation process and intervention adherence.A number of additional contextual factors emerged as enablers  or barriers  to the implementation of typhoid-relevant interventions in these countries. Some of these were common across countries , whereas others were country-specific . Some of the barriers identified in the present study aligned with those noted in a review by Puchalski Ritchie et al.Several limitations to the present study are noted. First, the number of key informants from each of the eight countries was relatively small, and this limited analyses of questionnaire data. Second, the study design would have been strengthened by document analysis to confirm and supplement the information provided by the key informants relative to the interventions they discussed. In the absence of validation from external documents, we rely solely on key informant recollections of typhoid control events over a 25 years period. Relatedly, we note that because of the small sample size across countries, the public health expertise of our key informants may not have been inclusive of all types of typhoid-relevant interventions implemented in their country, and thus, it is likely that interventions other than the ones identified in the present study were implemented either nationally or subnationally. Finally, there are insufficient data to allow reliable linkage of typhoid-relevant interventions and contextual implementation factors with actual changes in typhoid rates. This level of analysis would have required country-level typhoid surveillance data, which are not available, and external documentation of dates and types of interventions implemented within each country over this 25-year period. Despite these limitations, our study findings provide an important starting point for future systematic investigations of typhoid control interventions and implementation of evidence-based health interventions in LMICs and endemic regions, and contribute to a body of research evidence seeking to validate and refine the CFIR.Supplemental appendix


Homeless individuals suffer and die disproportionately from chronic diseases and disorders. We describe the epidemiology of cancer among homeless persons in metropolitan Detroit.A retrospective cohort study was performed using 1973–2014 data from the Metropolitan Detroit Cancer Surveillance System, a population-based cancer registry and member of the National Institutes of Health-National Cancer Institute’s Surveillance, Epidemiology, and End Results program. Homeless adults were identified through address at diagnosis listed as a homeless shelter, hospital, or supplemental field indicating homelessness. Age-adjusted, sex-specific proportional incidence ratios (PIR) compared cancer incidence proportions by primary tumor site of homeless patients to the nonhomeless referent population. Kaplan-Meier curves depicted unadjusted survival differences in a propensity score matched sample. Differences in 10-year survival were assessed using the score test with a sandwich estimator accounting for matched cluster effects. Statistical tests were two-sided.P < .001; cancer-reported survival, 38.0 vs 64.0 months, respectively, P  < .001).A total of 388 individuals experienced homelessness at first primary invasive cancer diagnosis. Statistically significantly higher proportions of respiratory system  and female genital system  cancers were observed among homeless men and women, respectively. Homeless persons had poorer overall and cancer-reported survival compared with a propensity score matched referent population (median: overall survival, 20.0 vs 38.0 months, respectively, Disparities in disease burden exist between adults who are experiencing homelessness compared with the nonhomeless population at cancer diagnosis. These findings provide clinically relevant information to understand the cancer burden in this medically underserved population and suggest an urgent need to develop cancer prevention and intervention programs to reduce disparities and improve the health of homeless persons. From its emergence as a national epidemic in the 1970s, homelessness has afflicted communities all across the United States . It is eAmong the largest cities in the Midwest, Detroit has garnered attention for its high rates of poverty—where nearly 4 out of every 10 residents live below the poverty level . RecentlWe compared patients who were experiencing homelessness with patients not identified as homeless (referent) at first primary invasive cancer diagnosis in the MDCSS catchment areas of Wayne, Oakland, and Macomb counties of southeast Michigan. The MDCSS is a founding member of the SEER program , which hThe United States Department of Health and Human Services defines a homeless individual as one who lacks housing (without regard as to whether the person is a member of a family), one whose primary residence during the night is a supervised public or private facility  that provides temporary living accommodations, or an individual who is a resident in transitional housing [42 U.S.C.§254b(h)(2017)]. For this study, individuals experiencing homelessness were identified based on the supplemental address field reporting “homeless,” “shelter,” or “lives in car,” or the address of diagnosis listed as a hospital or a homeless shelter . Our cohhttps://seer.cancer.gov/siterecode/icdo3_dwhoheme/). Cause-of-death classification was based upon the primary cause of death listed on the death certificate .Variables of interest included patient sex, age at diagnosis, race, SEER summary stage, type of reporting source, and year and county of diagnosis. International Classification of Diseases for Oncology site codes were used to define tumor location by primary site and histology according to standard SEER recodes . All statistical tests were two-sided, with a Age-adjusted, sex-specific proportional incidence ratios (PIRs) and 95% confidence intervals were calculated comparing 388 individuals in the homeless population with 654 672 individuals in the referent population  using thCalculations were sex specific and adjusted for age using the indirect method with six age groups  . PIRs grd = 0.10 or greater (10%) indicates a clinically relevant difference between matched homeless and referent cohorts. Using the Greedy propensity score matching algorithm , calculated using reverse Kaplan-Meier analysis ,29. KaplP < .0001). Together, 31.4% of all cancer cases in the homeless adult population were diagnosed among individuals 65 years of age and older . Compared with the referent population diagnosed with cancer in metropolitan Detroit, individuals experiencing homelessness at first primary cancer diagnosis were more likely to be male, black, and diagnosed at younger ages  .To assess disparities in survival between the homeless and nonhomeless referent populations diagnosed with a first primary invasive cancer in metropolitan Detroit, we propensity score matched 377 individuals who were homeless at cancer diagnosis to 1131 individuals from the referent population diagnosed with cancer  by demog < .001) . Nearly Our investigation of the burden of cancer among individuals who were experiencing homelessness, as compared with nonhomeless, at diagnosis of first primary invasive cancer in metropolitan Detroit revealed that proportions of cancers of the respiratory system, in particular malignancies of the lung and bronchus, were statistically significantly higher among homeless men when compared with the referent adult population of men diagnosed with cancer. Statistically significantly higher proportions of female genital system cancers, particularly cancers of the cervix uteri and ovary, were observed among homeless women. Together, homeless cancer patients exhibited statistically significantly poorer overall and cancer-reported survival when compared with a propensity score matched referent group. Our study is novel in that it is the first, to our knowledge, to examine the burden of cancer among homeless persons in the Midwest region of the United States, and the first, to our knowledge, to use propensity score matched cohorts to assess the impact of homelessness on cancer outcome.Across tumor types, early detection of cancer at local disease stage tends to be associated with better prognosis and survival outcomes. In our population of adults who were experiencing homelessness at first primary invasive cancer diagnosis, we found that nearly one-half of cancer cases were diagnosed at distant or unknown tumor stages. Individuals who were homeless at diagnosis of first primary invasive cancer in metropolitan Detroit had statistically significantly lower median survival months and poorer 10-year overall, as well as cancer-reported, survival outcomes compared with propensity score matched cases from the nonhomeless referent population. Previous studies have identified fear, and lack of opportunities and information, as barriers to cancer screening and early detection among homeless persons ,18,19. IThe entire population of homeless individuals is at high risk of death from various competing causes ,7,8. AltThe proportion of incident female genital system cancer cases was statistically significantly higher among homeless women in Detroit compared with the nonhomeless referent population of women diagnosed with cancer. Previous studies have demonstrated that homeless women tend to engage in more high-risk sexual behaviors and have more sexual partners than stably housed women, with concomitant exposure to blood-borne and sexually transmitted infections ,16,20. TAlthough our findings suggest that disparities in the cancer burden exist between patients who are homeless compared with the nonhomeless referent adult population diagnosed with a first primary invasive cancer in metropolitan Detroit, we acknowledge the limitations of our study. Our analyses were conducted using high-quality data from the MDCSS that allowed for pathologically verified cases to be identified and provided patient address information at time of cancer diagnosis. However, there remains a likelihood of the under-ascertainment of cancer cases among homeless individuals in metropolitan Detroit over the study period, which led to small sample sizes across particular primary tumor sites  due in part to hospital intake record requirements for a complete address field. Self-reporting of homeless patient addresses could also have included last place of residence or known family address and do not account for duration of homelessness. However, the concordance of our findings with prior studies of lung and cervical cancer among homeless individuals in Boston and Scotland ,37, and In conclusion, disparities in cancer incidence and outcomes exist between patients who are identified at diagnosis as homeless compared with the nonhomeless referent adult population diagnosed with a first primary invasive cancer in metropolitan Detroit. The results from this study provide clinically relevant information to begin understanding the burden of cancer within the high-risk population of homeless individuals in metropolitan Detroit, and may be useful for other urban areas with similar populations and challenges.This work was partially supported by funding from the Komen for the Cure Graduate Training in Disparities Research Program (GTDR14299438) Fellowship to ANH and MLC, the Cancer Biology Graduate Program at the Wayne State University School of Medicine and Barbara Ann Karmanos Cancer Institute to ANH, and National Institutes of Health under Ruth L. Kirschstein National Research Service Award T32 HG008962 from the National Human Genome Research Institute to ANH, for design and conduct of the study and collection, management, analysis, and interpretation of the data. This work was also supported, in part, by: the Epidemiology Research Core and NIH Center Grant P30 CA022453 to the Karmanos Cancer Institute at Wayne State University and Health and Human Services contract HHSN2612013011I for conduct of the study, and by the University of Utah Study Design and Biostatistics Center, with funding in part from the Huntsman Cancer Institute, the National Cancer Institute of the National Institutes of Health under Award Number P30 CA042014, the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant 8UL1TR000105 (formerly UL1RR025764).Affiliations of authors: Department of Oncology , Michael and Marian Ilitch Department of Surgery (DHG), Department of Urology (JAT), and Department of Family Medicine and Public Health Sciences (KLS), Wayne State University School of Medicine, Detroit, MI; Barbara Ann Karmanos Cancer Institute, Detroit, MI ; Huntsman Cancer Institute, Salt Lake City, UT ; Department of Population Health Sciences, University of Utah, Salt Lake City, UT (ANH).The authors declare no potential conflicts of interest with this work.We acknowledge the Coalition on Temporary Shelter (COTS), Department of Veterans Affairs at the John D. Dingell Medical Center, and the Community Housing Network, Inc for sharing their resources to aid in this study. We also thank these organizations, as well as other local facilities, for their sustained efforts to help individuals experiencing homelessness in our metropolitan Detroit community.ANH, KLS, MLC, and EIH contributed to the conception and design of the study. All authors participated in the acquisition, analysis and interpretation of data; and drafting and critical revision of the manuscript for important intellectual content. ANH, LMP, and JJR participated in the statistical analysis and in creating figures. ANH, KLS, MLC, AGS, JLB, and EIH obtained funding and provided support and supervision for this study. ANH and KLS had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.This study was determined nonhuman participant research by the Wayne State University Institutional Review Board.Supplementary DataClick here for additional data file.