Can training non-physician clinicians/associate clinicians (NPCs/ACs) in emergency obstetric, neonatal care and clinical leadership make a difference to practice and help towards reductions in maternal and neonatal mortality in rural Tanzania? The ETATMBA project

"I Need to Be the First One with a Different Approach and to Make a Difference to the People": A Mixed Methods Pilot Study on Non-Physician Clinicians Training in Malawi

PURPOSE

To improve child health care depends on the availability of sufficient numbers of skilled healthcare workers. To achieve this, the German Society of Tropical Paediatrics & International Child Health supported the existing three-year Bachelor of Science in Paediatrics and Child Health training for Clinical Officers, a non-physician clinician cadre, from 09/2017 to 08/2019. This study aims to evaluate the project to inform forthcoming training.

METHODS

All 17 students who were in training took part in this study. Quantitative data collection took place between 01/2018 to 06/2019 using the post-self-assessment bloc course survey, Research Self-Efficacy Scale (RSES), and Stages of Change (SOC) model. Students and key informants participated in three focus group discussions and five in-depth interviews during April 1-10, 2019.

RESULTS

Students mostly perceived bloc course contents "At their level" (92%) and "Very important/relevant" (61%) with "Good quality" teaching (70.5%). The mean (SD) score for RSES (10-point scale) was 9.10 (0.91). The SOC (4-point scale) scores were higher for "Attitude" and "Intention" statements than "Action". Students found the program well-paced, felt that their clinical knowledge and skills had improved, and valued the acquired holistic disease management approach. They reported increased confidence and being more prepared for leadership roles in their future work. The involvement of international teachers and supervisors enriched their global perspectives.

CONCLUSION

Students improved their clinical and non-clinical skills, developed self-efficacy and attitudes toward research, and were confident to build and utilize their networks. These transformative experiences could facilitate the development of change agents among current and future trainees.

Clinical associate students' perceptions of factors that influence their developing professional identity: a qualitative study

BACKGROUND

New cadres of clinicians, known as clinical associates, physician assistants, or clinical officers have evolved globally within many health systems to broaden access to care by increasing human resources. The training of clinical associates started in 2009 in South Africa, entailing the attainment of knowledge, clinical skills, and attitude competencies. Less formal educational attention has been focused on the process of developing personal and professional identities.

METHOD

This study utilized a qualitative interpretivist approach to explore professional identity development. A convenient sample of 42 clinical associate students at the University of Witwatersrand in Johannesburg were interviewed using focus groups to explore their perceptions of factors that influenced their professional identity formation. A semi-structured interview guide was used in six focus group discussions, involving 22 first-year and 20 third-year students. The transcriptions from the focus group audio recordings were thematically analyzed.

RESULTS

The multi-dimensional and complex factors that were identified were organized into three overarching themes, identified as individual factors which derive from personal needs and aspirations, training-related factors consisting of influences from the academic platforms, and lastly, student perceptions of the collective identity of the clinical associate profession influenced their developing professional identity.

CONCLUSION

The newness of the identity of the profession in South Africa has contributed to dissonance in student identities. The study recognizes an opportunity for strengthening the identity of the clinical associate profession in South Africa through improving educational platforms to limit barriers to identity development and effectively enhancing the role and integration of the profession in the healthcare system. This can be achieved by increasing stakeholder advocacy, communities of practice, inter-professional education, and the visibility of role models.

Oral Health Workforce in Africa: A Scarce Resource

The World Health Organization (WHO) African Region (AFR) has 47 countries. The aim of this research was to review the oral health workforce (OHWF) comprising dentists, dental assistants and therapists, and dental prosthetic technicians in the AFR. OHWF data from a survey of all 47 member states were triangulated with the National Health Workforce Accounts and population data. Descriptive analysis of workforce trends and densities per 10,000 population from 2000 to 2019 was performed, and perceived workforce challenges/possible solutions were suggested. Linear regression modelling used the Human Development Index (HDI), years of schooling, dental schools, and levels of urbanization as predictors of dentist density. Despite a growth of 63.6% since 2010, the current workforce density of dentists (per 10,000 population) in the AFR remains very low at 0.44, with marked intra-regional inequity (Seychelles, 4.297; South Sudan 0.003). The stock of dentists just exceeds that of dental assistants/therapists (1:0.91). Workforce density of dentists and the OHWF overall was strongly associated with the HDI and mean years of schooling. The dominant perceived challenge was identified as 'mal-distribution of the workforce (urban/rural)' and 'oral health' being 'considered low priority'. Action to 'strengthen oral health policy' and provide 'incentives to work in underserved areas' were considered important solutions in the region. Whilst utilising workforce skill mix contributes to overall capacity, there is a stark deficit of human resources for oral health in the AFR. There is an urgent need to strengthen policy, health, and education systems to expand the OHWF using innovative workforce models to meet the needs of this region and achieve Universal Health Coverage (UHC).

Remote Training for Medical Staff in Low-Resource Environments Using Augmented Reality

This work aims to leverage medical augmented reality (AR) technology to counter the shortage of medical experts in low-resource environments. We present a complete and cross-platform proof-of-concept AR system that enables remote users to teach and train medical procedures without expensive medical equipment or external sensors. By seeing the 3D viewpoint and head movements of the teacher, the student can follow the teacher's actions on the real patient. Alternatively, it is possible to stream the 3D view of the patient from the student to the teacher, allowing the teacher to guide the student during the remote session. A pilot study of our system shows that it is easy to transfer detailed instructions through this remote teaching system and that the interface is easily accessible and intuitive for users. We provide a performant pipeline that synchronizes, compresses, and streams sensor data through parallel efficiency.

" … we were like tourists in the theatre, the interns assisted almost all procedures … " Challenges facing the assistant medical officers training for the performance of caesarean section delivery in Tanzania

BACKGROUND

Training of mid-level providers is a task-sharing strategy that has gained popularity in the recent past for addressing the critical shortage of the health workforce. In Tanzania, training of mid-level providers has existed for over five decades; however, concerns exist regarding the quality of mid-level cadres amidst the growing number of medical universities. This study sought to explore the challenges facing the Assistant Medical Officers training for the performance of Caesarean section delivery in Tanzania.

METHODS

An exploratory qualitative case study was carried out in four regions to include one rural district in each of the selected regions and two AMO training colleges in Tanzania. A semi-structured interview guide was used to interview 29 key informants from the district hospitals, district management, regional management, AMO training college, and one retired AMO. Also, four focus group discussions were conducted with 35 AMO trainees.

RESULTS

Training of AMOs in Tanzania faces many challenges. The challenges include: use of outdated and static curriculum, inadequate tutors (lack of teaching skills and experience of teaching adults), inadequate teaching infrastructure in the existence of many other trainees, including interns, and limited or lack of scholarships and sponsorship for the AMO trainees.

CONCLUSIONS

The findings of this study underscore that the challenges facing AMO training for the performance of Caesarean section delivery have the potential to negatively impact the quality of Caesarean sections performed by this cadre. A holistic approach is needed in addressing these challenges. The solutions should focus on reviewing the curriculum, deploying qualified tutors, and improving the competencies of the available tutors through continuing medical education programmes. Furthermore, the government in collaboration with other stakeholders should work together to address the challenges in teaching infrastructure and providing financial support to this cadre that has continued to be the backbone of primary healthcare in Tanzania. Long-term solutions should consider deploying medical officers at the primary facilities and phasing out the performance of Caesarean section by AMOs.

What benefits do healthcare organisations receive from leadership and management development programmes? A systematic review of the evidence

Introduction

Leadership and management training/development programmes have gained increasing institutional attention in healthcare organisations, and they have a wide variety of formats and approaches. However, limited evidence exists about effects of these programmes for the organisations that sponsor them. A minority of healthcare systems in the USA measure the impact of these programmes on organisational metrics such as staff turnover or cost savings. This systematic review sought to answer the question, ‘What evidence exists that leadership and/or management development and training programs yield benefits for health care organizations?’ These benefits could include return on investment, improved productivity/cohesion/teaming, or increased use of specific management skills (eg, strategic planning) that would directly benefit the organisation.

Methods

We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to conduct a systematic review of the relevant literature. We conducted two searches in PubMed and one in ABI/Inform, a business literature database. All articles included for the study were further categorised according to their relevance for answering the research questions, using predefined criteria based on their methodology and reported findings.

Results

Our search included 2462 studies, of which 55 met criteria for inclusion. We identified four potential organisation-level benefits to leadership and management training programmes: benefits to other staff (besides those who participate in the programmes), improved patient safety and satisfaction, tangible benefits from projects that were part of the programme and improved ability/confidence using leadership-related skills by programme participants. However, the research base on this topic is limited.

Conclusion

Although this research identified potential benefits of leadership and management programmes at the organisation level, additional research is needed to make definitive conclusions about their impact.

The Tanzanian assistant medical officer

Tanzania, in East Africa, has one of the lowest numbers of physician per population in the world, especially in rural areas where most people live. To address this shortage, assistant medical officers (AMOs) were developed in the 1960s. AMOs are trained in an abbreviated medical school program, work independently, remain the highest-trained practitioners in rural practice, and provide most emergency surgical obstetric care in nonurban settings. Although information on AMOs is limited, no evidence has emerged that their patient care outcomes differ from physicians. These healthcare professionals, similar to physician assistants, have expanded access to care in severely underserved areas of the country. With a growing demand for contemporary healthcare and stretched service delivery, more research is needed on the ameliorating effect AMOs have on Tanzanian healthcare, especially as the country considers converting AMO training programs to medical school programs.

Technology-Based Newborn Health Learning Initiatives for Facility-Based Nurses and Midwives in Low- and Middle-Income Countries: A Scoping Review

PURPOSE

Given high neonatal mortality in many low- and middle-income countries, addressing missed opportunities by enhancing the quality of newborn care provided by facility-based nurses and midwives is critical. This scoping review synthesizes and critiques the literature on technology-based newborn health learning initiatives. Kirkpatrick's model is used for training program evaluation.

METHODS

A literature review was conducted from multiple databases. Articles selected for analysis consisted of original research studies published in peer-reviewed journals from 2012 to 2017.

RESULTS

Twelve studies fell into two categories: (a) Simulation training in routine neonatal care and newborn resuscitation (n = 9) and (b) eLearning initiatives (n = 3). Most studies evaluated health provider's knowledge and skills before and/or after training (n = 9); fewer evaluated the effect on change in provider practice (n = 3) and/or patient health outcomes (n = 5) (Kirkpatrick levels 3–4). Few studies utilized robust study designs and validated measurement instruments.

CONCLUSION

Learning approaches emphasizing simulation training and eLearning initiatives for facility-based health workers hold promise. However, existing simulation literature demonstrates that translation of knowledge gained during simulation into improved clinical outcomes in real births is variable. Additionally, the volume of peer-reviewed evidence demonstrating the potential benefit of eLearning strategies, especially in the neonatal period, is limited.

mLearning in the Democratic Republic of the Congo: A Mixed-Methods Feasibility and Pilot Cluster Randomized Trial Using the Safe Delivery App

Health worker knowledge and self-confidence in basic emergency obstetric and newborn care (BEmONC) increased significantly 3 months after introduction of the Safe Delivery App in intervention facilities compared with controls.

Background:

Substandard delivery care has been widely documented as a major cause of maternal mortality in health facilities globally. Health worker learning via mobile devices is increasing rapidly; however, there is little evidence of mLearning effectiveness. This study sought to determine the feasibility, acceptability, and potential effect of the Safe Delivery App (SDA) on health workers' practices in basic emergency obstetric and newborn care (BEmONC) in the Democratic Republic of the Congo (DRC). The Theoretical Domains Framework was used to guide this research.

Methods:

Eight BEmONC facilities in central DRC were randomized to either an mLearning intervention or to standard practice (control). Maternal and newborn health workers in intervention facilities (n=64) were trained on the use of smartphones and the French version of the SDA. The SDA is an evidence-based BEmONC training resource with visual guidance using animated videos and clinical management instructions developed by the Maternity Foundation and the Universities of Copenhagen and Southern Denmark. Knowledge on postpartum hemorrhage (PPH) and neonatal resuscitation (NR) and self-confidence in performing 12 BEmONC procedures were assessed at baseline and at 3 months post-intervention. Eighteen qualitative interviews were conducted with app users and key stakeholders to assess feasibility and acceptability of mLearning and the use of the SDA. Maternal mortality was compared in intervention and control facilities using a smartphone-based Open Data Kit (ODK) data application. One smartphone with SDA and ODK was entrusted to intervention facilities for the study period, whereas control facilities received smartphones with ODK only.

Results:

The analysis included 62 heath workers. Knowledge scores on postpartum hemorrhage and neonatal resuscitation increased significantly from baseline among intervention participants compared with controls at 3 months post-intervention (mean difference for PPH knowledge, 17.4 out of 100; 95% confidence interval [CI]=10.7 to 24.0 and 19.4 for NR knowledge; 95% CI=11.4 to 27.4), as did self-confidence scores on 12 essential BEmONC procedures (mean difference, 4.2 out of 48; CI=0.7 to 7.7). Increases were unaffected by health worker cadre and previous smartphone use. Qualitative interviews supported the feasibility and acceptability of the SDA and mLearning, and the potential for it to impact maternal and neonatal mortality in the DRC.

Conclusion:

Use of the Safe Delivery App supported increased health worker knowledge and self-confidence in the management of obstetric and newborn emergencies after 3 months. SDA and mLearning were found to be feasible and acceptable to health workers and key stakeholders in the DRC.

Up-skilling associate clinicians in Malawi in emergency obstetric, neonatal care and clinical leadership: the ETATMBA cluster randomised controlled trial

Background

The ETATMBA (Enhancing Training And Technology for Mothers and Babies in Africa) project-trained associate clinicians (ACs/clinical officers) as advanced clinical leaders in emergency obstetric and neonatal care. This trial aimed to evaluate the impact of training on obstetric health outcomes in Malawi.

Method

A cluster randomised controlled trial with 14 districts of Malawi (8 intervention, 6 control) as units of randomisation. Intervention districts housed the 46 ACs who received the training programme. The primary outcome was district (health facility-based) perinatal mortality rates. Secondary outcomes included maternal mortality ratios, neonatal mortality rate, obstetric and birth variables. The study period was 2011–2013. Mortality rates/ratios were examined using an interrupted time series (ITS) to identify trends over time.

Results

The ITS reveals an improving trend in perinatal mortality across both groups, but better in the control group (intervention, effect −3.58, SE 2.65, CI (−9.85 to 2.69), p=0.20; control, effect −17.79, SE 6.83, CI (−33.95 to −1.64), p=0.03). Maternal mortality ratios are seen to have improved in intervention districts while worsening in the control districts (intervention, effect −38.11, SE 50.30, CI (−157.06 to 80.84), p=0.47; control, effect 11.55, SE 87.72, CI (−195.87 to 218.98), p=0.90). There was a 31% drop in neonatal mortality rate in intervention districts while in control districts, the rate rises by 2%. There are no significant differences in the other secondary outcomes.

Conclusions

This is one of the first randomised studies looking at the effect of structured training on health outcomes in this setting. Notwithstanding a number of limitations, this study suggests that up-skilling this cadre is possible, and could impact positively on health outcomes.

Trial registration number

ISRCTN63294155; Results.

Defining Sub-Saharan Africa's Health Workforce Needs: Going Forwards Quickly Into the Past Comment on "Non-physician Clinicians in Sub-Saharan Africa and the Evolving Role of Physicians"

Recent proposals for re-defining the roles Africa’s health workforce are a continuation of the discussions that have been held since colonial times. The proposals have centred on basing the continent’s healthcare delivery on non-physician clinicians (NPCs) who can be quickly trained and widely distributed to treat majority of the common diseases. Whilst seemingly logical, the success of these proposals will depend on the development of clearly defined professional duties for each cadre of healthcare workers (HCW) taking the peculiarities of each country into consideration. As such the continent-wide efforts aimed at health-professional curriculum reforms, more effective utilisation of task-shifting as well as the intra – and inter-disciplinary collaborations must be encouraged. Since physicians play a major role in the training mentoring and supervision of physician and non-physician health-workers alike, the maintenance of the standards of university medical education is central to the success of all health system models. It must also be recognized that, efforts at improving Africa’s health systems can only succeed if the necessary socio-economic, educational, and technological infrastructure are in place.

A qualitative process evaluation of training for non-physician clinicians/associate clinicians (NPCs/ACs) in emergency maternal, neonatal care and clinical leadership, impact on clinical services improvements in rural Tanzania: the ETATMBA project

OBJECTIVES

The Enhancing Human Resources and Use of Appropriate Training for Maternal and Perinatal Survival in sub-Saharan Africa (ETATMBA) project is training non-physician clinicians as advanced clinical leaders in emergency maternal and newborn care in Tanzania and Malawi. The main aims of this process evaluation were to explore the implementation of the programme of training in Tanzania, how it was received, how or if the training has been implemented into practice and the challenges faced along the way.

DESIGN

Qualitative interviews with trainees, trainers, district officers and others exploring the application of the training into practice.

PARTICIPANTS

During late 2010 and 2011, 36 trainees including 19 assistant medical officers one senior clinical officer and 16 nurse midwives/nurses (anaesthesia) were recruited from districts across rural Tanzania and invited to join the ETATMBA training programme.

RESULTS

Trainees (n=36) completed the training returning to 17 facilities, two left and one died shortly after training. Of the remaining trainees, 27 were interviewed at their health facility. Training was well received and knowledge and skills were increased. There were a number of challenges faced by trainees, not least that their new skills could not be practised because the facilities they returned to were not upgraded. Nonetheless, there is evidence that the training is having an effect locally on health outcomes, like maternal and neonatal mortality, and the trainees are sharing their new knowledge and skills with others.

CONCLUSIONS

The outcome of this evaluation is encouraging but highlights that there are many ongoing challenges relating to infrastructure (including appropriate facilities, electricity and water) and the availability of basic supplies and drugs. This cadre of workers is a dedicated and valuable resource that can make a difference, which with better support could make a greater contribution to healthcare in the country.