Pilot study of quality of care training and knowledge in Sub-Saharan African medical schools

Quality of clinical management of children diagnosed with malaria: A cross-sectional assessment in 9 sub-Saharan African countries between 2007-2018

BACKGROUND

Appropriate clinical management of malaria in children is critical for preventing progression to severe disease and for reducing the continued high burden of malaria mortality. This study aimed to assess the quality of care provided to children under 5 diagnosed with malaria across 9 sub-Saharan African countries.

METHODS AND FINDINGS

We used data from the Service Provision Assessment (SPA) survey. SPAs are nationally representative facility surveys capturing quality of sick-child care, facility readiness, and provider and patient characteristics. The data set contained 24,756 direct clinical observations of outpatient sick-child visits across 9 countries, including Uganda (2007), Rwanda (2007), Namibia (2009), Kenya (2010), Malawi (2013), Senegal (2013-2017), Ethiopia (2014), Tanzania (2015), and Democratic Republic of the Congo (2018). We assessed the proportion of children with a malaria diagnosis who received a blood test diagnosis and an appropriate antimalarial. We used multilevel logistic regression to assess facility and provider and patient characteristics associated with these outcomes. Subgroup analyses with the 2013-2018 country surveys only were conducted for all outcomes. Children observed were on average 20.5 months old and were most commonly diagnosed with respiratory infection (47.7%), malaria (29.7%), and/or gastrointestinal infection (19.7%). Among the 7,340 children with a malaria diagnosis, 32.5% (95% CI: 30.3%-34.7%) received both a blood-test-based diagnosis and an appropriate antimalarial. The proportion of children with a blood test diagnosis and an appropriate antimalarial ranged from 3.4% to 57.1% across countries. In the more recent surveys (2013-2018), 40.7% (95% CI: 37.7%-43.6%) of children with a malaria diagnosis received both a blood test diagnosis and appropriate antimalarial. Roughly 20% of children diagnosed with malaria received no antimalarial at all, and nearly 10% received oral artemisinin monotherapy, which is not recommended because of concerns regarding parasite resistance. Receipt of a blood test diagnosis and appropriate antimalarial was positively correlated with being seen at a facility with diagnostic equipment in stock (adjusted OR 3.67; 95% CI: 2.72-4.95) and, in the 2013-2018 subsample, with being seen at a facility with Artemisinin Combination Therapies (ACTs) in stock (adjusted OR 1.60; 95% CI:1.04-2.46). However, even if all children diagnosed with malaria were seen by a trained provider at a facility with diagnostics and medicines in stock, only a predicted 37.2% (95% CI: 34.2%-40.1%) would have received a blood test and appropriate antimalarial (44.4% for the 2013-2018 subsample). Study limitations include the lack of confirmed malaria test results for most survey years, the inability to distinguish between a diagnosis of uncomplicated or severe malaria, the absence of other relevant indicators of quality of care including dosing and examinations, and that only 9 countries were studied.

CONCLUSIONS

In this study, we found that a majority of children diagnosed with malaria across the 9 surveyed sub-Saharan African countries did not receive recommended care. Clinical management is positively correlated with the stocking of essential commodities and is somewhat improved in more recent years, but important quality gaps remain in the countries studied. Continued reductions in malaria mortality will require a bigger push toward quality improvements in clinical care.

Assessment of nursing students perceptions of their training hospital's infection prevention climate: A multi-university study in Saudi Arabia

BACKGROUND

The risk of acquiring and spreading infection must be minimized in nursing students because they are exposed to healthcare-associated infections during clinical training. To achieve this goal, students should be knowledgeable and competent in infection control practice before proceeding to their training hospitals.

OBJECTIVES

This study assessed the nursing students' perception of the infection prevention climate in training hospitals in Saudi Arabia. It also examined the predictors of the students' perceptions.

DESIGN

A quantitative, cross-sectional design was used.

METHODS

This investigation was part of a large study conducted in six Saudi universities. A total of 829 Saudi nursing students were included in this study. Data were collected using the Leading Culture of Quality in Infection Prevention scale and analyzed using descriptive and inferential statistics. Ethical approval was obtained from the King Saud University, and permission was given by the administration of each participating university.

RESULTS

The overall perception of nursing students indicated a modest infection prevention climate. Prioritization of quality and improvement orientation was rated as the highest dimensions, whereas psychological safety and supportive environment were the lowest. The nursing students in University F had the poorest perceptions among the six universities. The predictors of nursing student perception of their training hospitals' infection prevention climates were the university where they studied, their age, and participation in infection prevention seminars.

CONCLUSIONS

This article describes nursing students' perception of the infection prevention climate of their training hospitals in Saudi Arabia. Results may provide a unique theoretical underpinning on the perception and factors that effect an infection prevention climate. Thereby, previous knowledge and literature may be expanded. Results can be used as a guide in establishing clinical policies in efforts toward improving the infection prevention climate.

Clinical performance among recent graduates in nine low- and middle-income countries

Objectives

Recent studies have identified large and systematic deficits in clinical care in low‐income countries that are likely to limit health gains. This has focused attention on effectiveness of pre‐service education. One approach to assessing this is observation of clinical performance among recent graduates providing care. However, no studies have assessed performance in a standard manner across countries. We analysed clinical performance among recently graduated providers in nine low‐ or middle‐income countries.

Methods

Service Provision Assessments from Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Tanzania, and Uganda were used. We constructed a Good Medical Practice Index that assesses completion of essential clinical actions using direct observations of care (range 0–1), calculated index scores by country and clinical cadre, and assessed the role of facility and clinical characteristics using regression analysis.

Results

Our sample consisted of 2223 clinicians with at least one observation of care. The Good Medical Practice score for the sample was 0.50 (SD = 0.20). Nurses and midwives had the highest score at 0.57 (SD = 0.20), followed by associate clinicians at 0.43 (SD = 0.18), and physicians at 0.42 (SD = 0.16). The average national performance varied from 0.63 (SD = 0.18) in Uganda to 0.39 (SD = 0.17) in Nepal, persisting after adjustment for facility and clinician characteristics.

Conclusions

These results show substantial gaps in clinical performance among recently graduated clinicians, raising concerns about models of clinical education. Competency‐based education should be considered to improve quality of care in LMICs. Observations of care offer important insight into the quality of clinical education.

Assessment of attitudes and targeted educational needs for refugee care providers in a Ugandan hospital

OBJECTIVES

To evaluate medical trainees' attitudes toward refugee patients in a refugee host country, and to identify educational needs.

METHODS

A 54-question cross-sectional questionnaire was administered to a convenience sample of 81 post-graduate medical trainees at Mbarara Regional Referral Hospital, Uganda, in 2016. Descriptive statistics on medical trainees' attitudes and educational needs regarding care for refugees were calculated. One-way ANOVA was used to assess relationships between an attitude scale and respondent characteristics. Reliability and validity of the survey items and attitude scale were assessed using Cronbach's alpha, item-to-scale correlation, and factor analysis.

RESULTS

The mean score on the attitude scale of 2.8 (SD=1.7) indicated positive attitudes toward refugees. All respondents had contact with refugees, and 89% (n=72) reported a need for further training. Many specifically indicated the need for training in use of translators, support personnel, and behavioral health.  Cronbach's alpha values of greater than 0.7 indicated good internal consistency. Item-to-scale correlation and factor analysis validate the use of an attitude scale. ANOVA showed no significant difference between mean attitude scores in gender (F_(1,77)=0.11, p=0.7367), country of origin (F_(1.78) =0.53, p=0.8723), or year of study (F_{(4,74) =}0.31, p=0.8273).

CONCLUSIONS

Medical trainees in Uganda report positive attitudes toward refugees and a need for additional education in refugee care in multiple specific areas. This study piloted the use of an attitude scale for refugee healthcare providers with promising validity and reliability. Use of these questions could inform curriculum development in refugee host countries.