Risk factors of MDR-TB and impacts of COVID-19 pandemic on escalating of MDR-TB incidence in lower-middle-income countries: A scoping review

The coronavirus disease 2019 (COVID-19) pandemic is affecting tuberculosis (TB) treatment in many ways that might lead to increasing the prevalence of multi-drugs-resistance tuberculosis (MDR-TB), especially in lower-middle-income-countries (LMICs). This scoping review aimed to identify the risk factors of MDR-TB and to determine the impacts of the COVID-19 pandemic on MDR-TB prevalence in LMICs. This study was reported according to the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (PRISMA-ScR) guideline. The relevant keywords were used to search studies in three databases (PubMed, ScienceDirect and SpringerLink) to identify the related articles. The English-written articles published from January 2012 to December 2022 that explored risk factors or causes of MDR-TB in LMICs were included. Out of 1,542 identified articles, 17 retrospective, prospective, case-control and cross-sectional studies from ten LMICs met were included in this scoping review. Twenty-one risk factors were discovered, with prior TB treatment (relapsed cases), diabetes, living area, living condition, smoking and low socioeconomic status were the main factors in developing MDR-TB during COVID-19 pandemic. The pandemic increased the MDR-TB prevalence through drug resistance transmission inside households, the distance between home and healthcare facilities and low socioeconomic status. This scoping review demonstrates how the COVID-19 pandemic has affected the rising incidence of MDR-TB in LMICs.

Domestic application of lessons learned by Canadian health care professionals working in international disaster settings: a qualitative research study

BACKGROUND

Individuals with prior experience in international disaster response represent an essential source of expertise to support disaster response in their home countries. Our objective was to explore the experiences of personnel involved in international emergency health response regarding their perceptions of essential disaster response attributes and capacities and determine how these competencies apply to the Canadian context.

METHODS

For this qualitative study, we conducted semistructured interviews with key informants in person or over the telephone from May to December 2018. Participants were delegates deployed as part of the Canadian Red Cross medical response team in a clinical or technical, or administrative role within the last 5 years. Interviews were audio-recorded and transcribed. Conventional content analysis was performed on the transcripts, and themes were developed.

RESULTS

Eighteen key informants from 4 Canadian provinces provided perspectives on individual attributes acquired during international deployments, such as agility and stress management, and team capacities developed, including collaboration and conflict management. Key informants, including administrators (n = 5), technicians (n = 4), nurses (n = 4), physicians (n = 3) and psychosocial support workers (n = 2), described these experiences as highly relevant to the Canadian domestic context.

INTERPRETATION

Canadian physicians and health care workers involved with international disaster response have already acquired essential capacities, and this experience can be vital to building efficient disaster response teams in Canada. These findings complement the Canadian Medical Education Directives for Specialists (CanMEDS) roles and can inform course design, competency and curriculum development for physician and professional training programs related to disaster response and preparedness.

Strengthening Primary Care Through Family Medicine Around the World Collaborating Toward Promising Practices

BACKGROUND AND OBJECTIVES

There is a limited evidentiary base on the development of family medicine in different contexts and countries. The lack of evidence impedes our ability to compare and characterize family medicine models and identify areas of success that have led to the effective provision of care. This paper offers a comparative compilation and analysis of the development of family medicine training programs in seven countries: Brazil, Canada, Ethiopia, Haiti, Indonesia, Kenya, and Mali.

METHODS

Using qualitative case studies, this paper examines the process of developing family medicine programs, including enabling strategies and barriers, and shared lessons. An appreciative inquiry framework and complex adaptive systems thinking inform our qualitative study.

RESULTS

Committed partnerships, the contribution of champions, health policy, and adaptability were identified as key enablers in all seven case studies. The case studies further reveal that some enablers were more salient in certain contexts as compared to others, and that it is the interaction of enablers that is crucial for understanding how and why initiatives succeeded. The barriers that emerged across the seven case studies include: (1) resistance from other medical specialties, (2) lack of resources and capabilities, (3) difficulty in sustaining support of champions, and (4) challenges in brokering effective partnerships.

CONCLUSIONS

A key insight from this study is that the implementation of family medicine is nonlinear, dynamic, and complex. The findings of this comparative analysis offer insights and strategies that can inform the design and development of family medicine programs elsewhere.

What are the family medicine faculty development needs of partners in low- and middle-income countries?

The WHO endorses family medicine (FM) globally to improve health outcomes. The Besrour Centre (BC) brings together partners from low- and middle-income countries (LMICs) to collaborate on FM development in different contexts. Faculty development is an identified area of need, but specific needs were unknown. A qualitative study was conducted using two 1-1.5-hour focus groups at the 2015 BC conference. Ten countries and 12 universities were represented. Transcripts from semi-structured interviews were analysed for themes using a descriptive approach. There was unanimous support for the need for faculty development tools and resources, particularly in teaching skills. Most programmes lacked formal structure or funding. A consistently identified concept was how to teach specialist faculty the FM context, as was the importance of FM perspective to inform government policies. The need for faculty development of FM in LMICs is strong. FM faculty development resources can be expanded and shared through global health networks. Further expansion of faculty development workshops and toolkits is recommended. This study adds to the current knowledge because it helps to identify the gaps and priorities, specifically focused on LMICs, when developing faculty development FM programmes.

Attitudes, barriers, and enablers towards conducting primary care research in Banda Aceh, Indonesia: a qualitative research study

BACKGROUND

Conducting university-based research is important for informing primary care, especially in lower- and middle- income countries (LMICs) such as Indonesia. Syiah Kuala University (SKU), the largest educational institution in Aceh province, Indonesia, is actively establishing itself as a leader in research innovation; however, this effort has not yet demonstrated optimum results. Understanding faculty members' perceptions of how research is conducted in this setting is crucial for the design and implementation of successful and sustainable research strategies to increase the quantity and quality of primary care research conducted at LMIC universities. The objective of this study was to identify current attitudes, barriers and enablers/facilitators towards primary care research participation and implementation in this higher education institution.

METHODS

A descriptive-interpretive qualitative study was conducted. 29 participants, representing 90% of all faculty members providing primary care, were included. A mixed-methods approach was used, combining the use of a participant survey with 10 focus group discussions. Participants were encouraged to complete the survey in either English or Bahasa Indonesia. All of the focus group discussions were recorded, transcribed and translated into English. Thematic content analysis of these transcripts was carried out.

RESULTS

The majority of participants agreed that SKU has set research as a priority, as it is one of the three pillars of higher education, mandatory in all Indonesian higher education institutions. This research identified many barriers in conducting research, i.e. weak research policy, lack of research funding and infrastructure, complicated research bureaucracy and administrative process, as well as time constraints for conducting research relative to other duties. Participants expressed that personal motivation was a very important enabler/facilitator for increasing research activities. In order to improve research productivity, the majority of participants suggested that having local awards and formal recognition, having the opportunity to partner with local business and communities, provision of incentives, and having access to a research help-desk would be beneficial.

CONCLUSIONS

Generally, participants showed a supportive and positive attitude towards research, and provided examples of how to improve research productivity in the Asian university context.

Lessons learned in global family medicine education from a Besrour Centre capacity-building workshop

At a global level, institutions and governments with remarkably different cultures and contexts are rapidly developing family medicine centred health and training programmes. Institutions with established family medicine programmes are willing to lend expertise to these global partners but run the risk of imposing a postcolonial, directive approach when providing consultancy and educational assistance. Reflecting upon a series of capacity building workshops in family medicine developed by the Besrour Centre Faculty Development Working Group, this paper outlines approaches to the inevitable challenges that arise between healthcare professionals and educators of differing contexts when attempting to share experience and expertise. Lessons learned from the developers of these workshops are presented in the desire to help others offer truly collaborative, context-centred faculty development activities that help emerging programmes develop their own clinical and educational family medicine frameworks. Established partner relationships, adequate preparation and consultation, and adaptability and sensitivity to partner context appear to be particularly significant determinants for success.

Understanding attitudes, barriers and challenges in a small island nation to disease and partner notification for HIV and other sexually transmitted infections: a qualitative study

BACKGROUND

In Barbados sexually transmitted infections (STIs) including HIV are not notifiable diseases and there is not a formal partner notification (PN) programme. Objectives were to understand likely attitudes, barriers, and challenges to introducing mandatory disease notification (DN) and partner notification (PN) for HIV and other STIs in a small island state.

METHODS

Six key informants identified study participants. Interviews were conducted, recorded, transcribed and analysed for content using standard methods.

RESULTS

Participants (16 males, 13 females, median age 59 years) included physicians, nurses, and representatives from governmental, youth, HIV, men's, women's, church, and private sector organisations. The median estimated acceptability by society of HIV/STI DN on a scale of 1 (unacceptable) to 5 (completely acceptable) was 3. Challenges included; maintaining confidentiality in a small island; public perception that confidentiality was poorly maintained; fear and stigma; testing might be deterred; reporting may not occur; enacting legislation would be difficult; and opposition by some opinion leaders. For PN, contract referral was the most acceptable method and provider referral the least. Contract referral unlike provider referral was not "a total suspension of rights" while taking into account that "people need a little gentle pressure sometimes". Extra counselling would be needed to elicit contacts or to get patients to notify partners. Shame, stigma and discrimination in a small society may make PN unacceptable and deter testing. With patient referral procrastination may occur, and partners may react violently and not come in for care. With provider referral patients may have concerns about confidentiality including neighbours becoming suspicious if a home visit is used as the contact method. Successful contact tracing required time and effort. With contract referral people may neither inform contacts nor say that they did not. Strategies to overcome barriers to DN and PN included public education, enacting appropriate legislation to allow DN and PN, good patient counselling and maintaining confidentiality.

CONCLUSIONS

There was both concern that mandatory DN and PN would deter testing and recognition of the benefits. Public and practitioner education and enabling legislation would be necessary, and the public needed to be convinced that confidentiality would be maintained.

'Before you teach me, I cannot know': immigrant women's barriers and enablers with regard to cervical cancer screening among different ethnolinguistic groups in Canada

OBJECTIVE

To describe the similarities and differences among multiple groups of immigrant women and Canadian-born women of low socio-economic status regarding barriers and enablers associated with cervical cancer screening, in order to inform core elements of a strategy that would be acceptable across multiple underscreened groups.

METHOD

Within a health behaviour framework, we used a qualitative explanatory multiple-case study approach consisting of focus group interviews (n = 11) in Hamilton, Canada. Participants were newly immigrated (1-5 years) women and a group of Canadian-born women of low socio-economic status; all participants were in the age range 35-69 years and married. Language groups were Arabic, Cantonese, Somali, Dari (Afghanistan) and Spanish (Latin America). Two separate focus groups for each ethnolinguistic group were conducted; one in English and one in the native language. A template approach to analysis was used.

RESULTS

All groups indicated a strong need for information on necessity of screening and on how the procedure is done. Use of a video and a group discussion format were desired strategies. Women had positive feelings about being proactive for their health even if prevention had not been the norm in their home countries. There were differences between groups with respect to preferring a female clinician, which was a higher priority than language congruence with the provider. Only Chinese and Arabic groups discussed embarrassment and modesty as barriers.

CONCLUSION

Addressing key knowledge gaps around cervical cancer screening through personal approaches, educational videos and invitations may be useful core strategies to remove stigma and fear around screening and improve uptake across multiple ethnic groups and in women of lower socioeconomic status.

Developing a curriculum framework for global health in family medicine: emerging principles, competencies, and educational approaches

BACKGROUND

Recognizing the growing demand from medical students and residents for more comprehensive global health training, and the paucity of explicit curricula on such issues, global health and curriculum experts from the six Ontario Family Medicine Residency Programs worked together to design a framework for global health curricula in family medicine training programs.

METHODS

A working group comprised of global health educators from Ontario's six medical schools conducted a scoping review of global health curricula, competencies, and pedagogical approaches. The working group then hosted a full day meeting, inviting experts in education, clinical care, family medicine and public health, and developed a consensus process and draft framework to design global health curricula. Through a series of weekly teleconferences over the next six months, the framework was revised and used to guide the identification of enabling global health competencies (behaviours, skills and attitudes) for Canadian Family Medicine training.

RESULTS

The main outcome was an evidence-informed interactive framework http://globalhealth.ennovativesolution.com/ to provide a shared foundation to guide the design, delivery and evaluation of global health education programs for Ontario's family medicine residency programs. The curriculum framework blended a definition and mission for global health training, core values and principles, global health competencies aligning with the Canadian Medical Education Directives for Specialists (CanMEDS) competencies, and key learning approaches. The framework guided the development of subsequent enabling competencies.

CONCLUSIONS

The shared curriculum framework can support the design, delivery and evaluation of global health curriculum in Canada and around the world, lay the foundation for research and development, provide consistency across programmes, and support the creation of learning and evaluation tools to align with the framework. The process used to develop this framework can be applied to other aspects of residency curriculum development.

Ethical issues encountered by medical students during international health electives

CONTEXT

Medical students increasingly wish to participate in international health electives (IHEs). The authors undertook to understand from the students' perspective the ethical challenges encountered on IHEs in low-resource settings and how students respond to these issues.

METHODS

Semi-structured interviews were conducted with 12 medical students upon their return from an IHE. A purposive sampling strategy was used. Inductive data analysis using a constant comparative technique generated initial codes which were later organised into higher-order themes.

RESULTS

Five themes relating to ethical issues were identified: (i) uncertainty about how best to help; (ii) perceptions of Western medical students as different; (iii) moving beyond one's scope of practice; (iv) navigating different cultures of medicine, and (v) unilateral capacity building.

CONCLUSIONS

International health electives are associated with a range of ethical issues for students. Students would benefit from formal pre-departure training, which should include an evaluation of their expectations of and motivations for participating in an IHE, careful selection of the IHE from amongst the opportunities available, learning about the local context of the IHE prior to departure, and the exploration and discussion of ethical and professionalism issues. Other factors that would benefit students include having an invested onsite colleague or supervisor, maintaining an ongoing connection with the home institution, and formal debriefing on conclusion of the IHE.

Barriers to acceptance of self-sampling for human papillomavirus across ethnolinguistic groups of women

OBJECTIVES

Immigrant and low socio-economic (SES) women in North America underutilize Papanicolaou screening. Vaginal swab self-sampling for oncogenic human papillomavirus (HPV) has the potential to increase cervical cancer screening participation. The purpose of this qualitative study was to understand the perceptions of lower SES and immigrant women regarding self-sampling for HPV.

METHODS

Eleven focus-group interviews were conducted: one with Canadian-born English-speaking lower SES women, and two groups each with Arabic, Cantonese, Dari (Afghani), Somali and Spanish (Latino)-speaking women (one group conducted in English, the other in the native language) recently immigrated to Canada. Five to nine women aged 35 to 65 years and married with children participated in each group.

RESULTS

Themes included 1) who might use self-sampling and why; 2) aversion to self-sampling and reasons to prefer physician; 3) ways to improve the appeal of self-sampling. Women generally perceived benefits of self-sampling and a small number felt they might use the method, but all groups had some reservations. Reasons included: uncertainty over performing the sampling correctly; fear of hurting themselves; concern about obtaining appropriate material; and concerns about test accuracy. Women preferred testing by a health care professional because they were accustomed to pelvic examinations, it was more convenient, or they trusted the results.

CONCLUSIONS

Perceptions of self-sampling for HPV were similar across cultures and pertained to issues of confidence in self-sampling and need for physician involvement in care. These findings can inform programs and studies planning to employ self-sampling as a screening modality for cervical cancer.

The 1999 international emergency humanitarian evacuation of the Kosovars to Canada: A qualitative study of service providers' perspectives at the international, national and local levels

BACKGROUND: In response to the Kosovo crisis, Canada received 5,500 Albanian Kosovar refugees in 1999 as part of the emergency humanitarian evacuation and settlement effort. This study attempts to describe the experiences of service providers at the international, national, and local levels, involved in the organization and delivery of health and settlement services in Canada for the Kosovar refugees. METHODS: A qualitative case study design using key informant interviews was used. Nominated sampling was used to identify 17 individuals involved in the organization and delivery of health and settlement. Key themes were identified and recommendations made to provide a framework for the development of policy to guide response to future humanitarian emergencies. RESULTS: Six themes emerged: (1) A sense of being overwhelmed, (2) A multitude of health issues, (3) critical challenges in providing health care, (4) access to health and settlement services, (5) overall successes and (6) need for a coordinated approach to migration health. CONCLUSIONS: For those involved, the experience was overwhelming but rewarding. Interviewees' major concerns were the need for a more comprehensive and coordinated approach to the flow of medical information and handling of specific health problems.

How are new refugees doing in Canada? Comparison of the health and settlement of the Kosovars and Czech Roma

BACKGROUND

In 1999, a group of Kosovars arrived in Hamilton, Ontario, with a coordinated international pre-migration plan, as part of the United Nations Humanitarian Evacuation Program. Since 1997, a substantial number of Roma refugees from the Czech Republic also arrived in Hamilton, with no special pre-migration planning. This study examined whether the organized settlement efforts led to better adaptation and perceived health for the Kosovars, using the Czech Roma as a comparison group.

METHODS

Adult members of 50 Kosovar (n=157 individuals) and 50 Czech Roma (n=76 individuals) randomly selected families completed a questionnaire on sociodemographics, health, well-being, and perceived adaptation to Canada. Differences between groups were examined using univariate and multivariate analyses. Comparison was made to the Ontario population where possible.

RESULTS

There were more Kosovars than Czech Roma over the age of 50 (22.1% vs 10.5%, p=0.03). Nearly one quarter (21.7%) of the Kosovars had a score indicating post-traumatic stress disorder (PTSD) on the Harvard Trauma Questionnaire (HTQ), compared to none of the Roma (p<0.001). After adjustment for age and PTSD, the Kosovars were significantly more likely to report fair or poor adaptation to Canada (OR=10.5, 95% CI=3.6-31.2) and that life is somewhat or very stressful (OR=3.9, 95% CI=2.1-7.4). Differences for other measures were no longer significant after adjustment.

CONCLUSIONS

The health and adaptation of the Kosovars was not better than that of the Czech Roma. Reasons for this finding may include differences in demographics, the presence of PTSD, and differing length of time since arrival in Canada.

The syndromic approach to treatment of sexually transmitted diseases in low-income countries: issues, challenges, and future directions

BACKGROUND

Sexually transmitted diseases (STDs) are a major cause of adult morbidity worldwide. In 1991, the World Health Organization (WHO) introduced the concept of the "syndromic approach" to managing sexually transmitted diseases in low-income countries, however, there has been some controversy regarding the ongoing use of this approach.

OBJECTIVES

(1) To understand the use of the syndromic approach to managing sexually transmitted diseases in low-income countries, and to determine if evidence supports its continued use. (2) To help Canadian doctors understand the past STD management of immigrant patients from low-income countries, and evaluate the direct effect (if any) of such medical practices to the patient's health and perception of health in Canada.

METHODS

Medline was searched under the key words "sexually transmitted diseases," "developing nations," and "syndrome," as well as "algorithms," "prevention and control," and "WHO." Research articles and data were also accessed from the Web sites of WHO, UNAIDS, Reproductive Health Online (JHSPH), and the Centers for Disease Control and Prevention (USA). Data were selected based on the relevance to the topic, and research articles assessed from a methodological perspective. Most research articles were of Level II-2 evidence or lower as described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Force on the Periodic Health Exam.

RESULTS

In resource-poor countries, the use of the syndromic approach is appropriate for high-risk groups and for symptomatic individuals. However, it is still a poor screening approach when applied to asymptomatic cases, particularly in women. Risk scoring and simple laboratory tests help to increase the algorithmic sensitivity of the syndromic approach.

CONCLUSION

Syndromic management involves making clinical decisions based on a patient's symptoms and signs. Until inexpensive, simple, and accurate STD diagnostics are developed and made available for use in low-income countries, a modified syndromic approach is the most feasible method of STD management in these countries. It is useful for Canadian physicians to be aware of this approach especially when caring for women from these countries.

Residents' exposure to aboriginal health issues. Survey of family medicine programs in Canada

OBJECTIVE

To determine whether Canadian family medicine residency programs currently have objectives, staff, and clinical experiences for adequately exposing residents to aboriginal health issues.

DESIGN

A one-page questionnaire was developed to survey the details of teaching about and exposure to aboriginal health issues.

SETTING

Family medicine programs in Canada.

PARTICIPANTS

All Canadian family medicine program directors in the 18 programs (16 at universities and two satellite programs) were surveyed between October 1997 and March 1998.

MAIN OUTCOME MEASURES

Whether programs had teaching objectives for exposing residents to aboriginal health issues, whether they had resource people available, what elective and core experiences in aboriginal health were offered, and what types of experiences were available.

RESULTS

Response rate was 100%. No programs had formal, written curriculum objectives for residency training in aboriginal health issues, although some were considering them. Some programs, however, had objectives for specific weekend or day sessions. No programs had a strategy for encouraging enrollment of residents of aboriginal origin. Eleven programs had at least one resource person with experience in aboriginal health issues, and 12 had access to community-based aboriginal groups. Core experiences were all weekend seminars or retreats. Elective experiences in aboriginal health were available in 16 programs, and 11 programs were active on reserves.

CONCLUSIONS

Many Canadian family medicine programs give residents some exposure to aboriginal health issues, but most need more expertise and direction on these issues. Some programs have unique approaches to teaching aboriginal health care that could be shared. Formalized objectives derived in collaboration with other family medicine programs and aboriginal groups could substantially improve the quality of education in aboriginal health care in Canada.

Health care work in developing countries

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