Lessons learned from early implementation of the Growing Expertise in E-health Knowledge and Skills (GEEKS) program in Nigeria, 2019 - 2021

Introduction

the Growing Expertise in E-health Knowledge and Skills (GEEKS) program is an applied apprenticeship program that aims to improve informatics capacity at various levels of the national health system and create a sustainable informatics workforce. Nigeria adapted the GEEKS model in 2019 as a mechanism to strengthen data quality and use of routine immunization (RI) and vaccine-preventable disease (VPD) surveillance data among Expanded Programme on Immunization (EPI) staff. Since the start of the GEEKS-EPI program, there has not been a formal assessment conducted to measure the extent to which GEEKS-EPI has been able to build local informatics workforce capacity and strengthen RI and VPD surveillance (VPDS) data quality and use in Nigeria.

Methods

we conducted a qualitative assessment to inform the extent to which GEEKS-EPI has been able to build informatics skillsets to enhance local workforce capacity, foster collaboration across government agencies, and create a sustainable informatics workforce in Nigeria. In-Depth Interviews (IDIs) and Focus Group Discussions (FGDs) were held with GEEKS-EPI supervisors, mentors, and mentees from previous GEEKS-EPI cohorts.

Results

while there were challenges reported during early implementation of the GEEKS-EPI program in Nigeria, particularly early on in the COVID-19 pandemic, participants and supervisors reported that the fellowship provided a framework for building a sustainable RI and VPDS informatics workforce through regular mentorship, peer-to-peer exchanges and Subject Matter Expert (SME)-led trainings.

Conclusion

lessons learned from early implementation of GEEKS-EPI in Nigeria will help to inform its implementation in other countries, where strengthened national RI and VPDS informatics capacity is the primary objective.

Effects of COVID-19 on Vaccine-Preventable Disease Surveillance Systems in the World Health Organization African Region, 2020

Global emergence of the COVID-19 pandemic in 2020 curtailed vaccine-preventable disease (VPD) surveillance activities, but little is known about which surveillance components were most affected. In May 2021, we surveyed 214 STOP (originally Stop Transmission of Polio) Program consultants to determine how VPD surveillance activities were affected by the COVID-19 pandemic throughout 2020, primarily in low- and middle-income countries, where program consultants are deployed. Our report highlights the responses from 154 (96%) of the 160 consultants deployed to the World Health Organization African Region, which comprises 75% (160/214) of all STOP Program consultants deployed globally in early 2021. Most survey respondents observed that VPD surveillance activities were somewhat or severely affected by the COVID-19 pandemic in 2020. Reprioritization of surveillance staff and changes in health-seeking behaviors were factors commonly perceived to decrease VPD surveillance activities. Our findings suggest the need for strategies to restore VPD surveillance to prepandemic levels.

Covalently grafted VEGF(165) in hydrogel models upregulates the cellular pathways associated with angiogenesis

Angiogenesis is an important biological response known to be involved in many physiological and pathophysiological situations. Cellular responses involved in the formation of new blood vessels, such as increases in endothelial cell proliferation, cell migration, and the survival of apoptosis-inducing events, have been associated with vascular endothelial growth factor isoform 165 (VEGF(165)). Current research in the areas of bioengineering and biomedical science has focused on developing polyethylene glycol (PEG)-based systems capable of initiating and sustaining angiogenesis in vitro. However, a thorough understanding of how endothelial cells respond at the molecular level to VEGF(165) incorporated into these systems has not yet been established in the literature. The goal of the current study was to compare the upregulation of key intracellular proteins involved in angiogenesis in human umbilical vein endothelial cells (HUVEC) and human microvascular endothelial cells (HMEC) seeded on PEG hydrogels containing grafted VEGF(165) and adhesion peptides Arg-Gly-Asp-Ser (RGDS). Our data suggest that the covalent incorporation of VEGF(165) into PEG hydrogels encourages the upregulation of signaling proteins responsible for increases in endothelial cell proliferation, cell migration, and the survival after apoptosis-inducing events.

Why do we have apocrine and sebaceous glands?

The secretions of sebaceous and apocrine glands fulfil an important thermoregulatory role in cold-stressed and heat-stressed hunter-gatherers. In hot conditions the secretions emulsify eccrine sweat and thus encourage the formation of a sweat sheet and discourage the formation and loss of sweat drops from the skin. In colder conditions sebum changes its nature and repels rain from skin and hair.

Misuse of correlation and regression in three medical journals

Errors relating to the use of the correlation coefficient and bivariate linear regression are often to be found in medical publications. This paper reports a literature search to define the problems. All the papers and letters published in the British Medical Journal, The Lancet and the New England Journal of Medicine during 1997 were screened for examples. Fifteen categories of errors were identified of which eight were important or common. These included: failure to define clearly the relevant sample number; the display of potentially misleading scatterplots; attachment of unwarranted importance to significance levels; and the omission of confidence intervals for correlation coefficients and around regression lines.

The chief scientist reports ... co-ordination of care on discharge from hospital into the community for patients with HIV/AIDS in Lothian

OBJECTIVE

To document service use by people living with HIV/AIDS discharged from hospital, to identify gaps and overlaps in service provision after discharge, and to evaluate liaison between hospital-based and community-based services.

DESIGN

Four week follow-up diary and interview study of service users, and interview/questionnaire study of service providers.

SETTING

Services used by people discharged from the wards of two units of two Lothian hospitals.

SUBJECTS

All patients with HIV infection admitted to the wards of two units of two Lothian hospitals from October 1992 to February 1993, and their service providers.

RESULTS AND CONCLUSION

General practitioners were the most contacted service post discharge, but general practitioners did not appear to play a co-ordination role in service provision. Liaison on discharge was found to be effective in terms of continuity of care in most cases; and from a service user perspective, liaison between hospital and primary care agencies did not appear a major concern. The majority of hospital discharges were organised in a setting with a large number of services, with complex communication patterns and informal procedures of discharge arrangements. This created uncertainty among service providers as to the arrangements which had been made, and fear and anxiety that they fall through. On the other hand, the informality of discharge procedures also ensured flexibility and responsiveness to unexpected events and changes in service users' circumstances and was a vital factor in continuity of care experienced by them. A more important issue for service users was the poor integration of services concerned with social/material support in the system of medical and emotional care.

Lothian general practitioners, HIV infection and drug misuse: epidemiology, experience and confidence 1988-1993

BACKGROUND

Lothian has a high prevalence rate of HIV infection associated particularly with injecting drug use in the mid-1980s. During the late 1980s a number of services were introduced to support general practitioners to care for drug users and people with HIV infection.

AIM

To ascertain the practice distribution of patients with HIV infection and drug users, and the experience and confidence of Lothian GPs in a number of HIV and drug related tasks, and to see how these changed over a five year period after the introduction of support services.

METHOD

Information about practice distribution of patients with HIV infection and drug users and information about GP experience and confidence was obtained from a survey of individual GPs in 1988. Two practice surveys in 1991 and 1993, using a chosen GP for each practice, gave information about practice distribution of people with HIV infection and drug users, while a second survey of individual GPs in 1993, concentrating on GP experience and confidence, acted as a follow up to the 1988 survey.

RESULTS

GPs are in touch with an increasing number of people with symptomatic HIV infection. They are increasingly involved and confident in caring for drug users. Offering support and training to GPs appears to have encouraged their involvement. There are a significant number of people with HIV infection in Lothian who are not known to GPs or to hospital services. A combination of practice and individual GP surveys was found to provide the most reliable information. It is planned to repeat the practice survey in 1995.

Heat illness and soldiers

Soldiers are probably more at risk for heat illness than marathon runners and the reasons for this contrast are examined. The epidemiology of heat illness is reviewed, the practice of making soldiers run in battle-order is criticized, and further areas for research are suggested.

The need for another look at the patient in general practice satisfaction surveys

Although patient satisfaction research has looked at the aspects of care which patients are satisfied with and at which patients are satisfied with their care, few studies have looked at which patients are satisfied with which aspects of care. A retrospective analysis of data collected from 1599 patients attending 43 GPs was undertaken to examine the way that different patient characteristics influenced responses to a 31 item survey completed at the surgery after a consultation. Information on perceived distress [as measured by the Nottingham Health Profile (NHP)] was collected from patients prior to the consultation and further information about the patient and the consultation was recorded by the doctor after the consultation. Levels of satisfaction were high, with only seven of 31 items producing more than 5% of negative responses. These seven items covered whether the waiting time was too long, whether the doctor was relaxed, whether the doctor was in a hurry, whether there was anything else the patient would have liked to talk about had there been more time, whether the doctor had said or done anything to reduce the patient's worries, whether the doctor gave the feeling that the patient's opinions were important and whether there was anything about the consultation which disappointed the patient. Age, waiting time prior to the consultation, consultation length and positive scores on the six NHP dimensions of distress were all significantly associated with responses to one or more of these seven items. Patients experiencing pain and those with emotional distress were dissatisfied with different aspects of the consultation.(ABSTRACT TRUNCATED AT 250 WORDS)

The chief scientist reports ... The Scottish general practice shadow fund-holding project--outline of an evaluation

After the agreement in January 1989 between the Minister of Health at the Scottish Office, Mr Michael Forsyth, and six groups of General Practitioners (GPs) in the Grampian and Tayside Regions of Scotland to embark on a 'shadow fund-holding' project, the Government agreed to promote an independent evaluation of the scheme. As a result, the Department of General Practice at Edinburgh University was invited to present plans to evaluate the working of and results of the scheme. Consultations with the Minister and Health Department officials, the general practices concerned, and staff of the two Health Boards involved took place during the first three months of 1990, and an outline protocol for the evaluation was approved and funded through the Chief Scientist Organisation for a three-year period from April 1990. It was agreed by all involved that piecemeal publications of results during the period of the research would be inappropriate, but with other attempts to evaluate fund-holding now being reported elsewhere in the UK, it has been agreed that an outline of issues being explored and the methods being used would be in the general interest. This paper first outlines the principal areas in which the evaluation is being focused, then describes the general methods being used, and finally comments on some of the problems encountered with the evaluation. The project should be seen as a descriptive beginning to what may well be a period of around a decade needed to appreciate the full implications of any major change in the organisation of health service provision.

Attaching prices to decision making in general practice

This paper is an attempt to evaluate the cost implications of decisions made by general practitioners during consultations. Prices were attached to the cost generating decisions of 85 general practitioners in South East Scotland who participated in a 12-month study of their workload. When the price attached to each referral decision was one out-patient attendance, 56 of the 85 general practitioners' costs per consultation were within 15% of the average cost, and 76 were within 25% of the average. However, when the price attached to referral activity was adjusted upwards (to allow for the inclusion of further hospital care), variations between doctors became more pronounced and the decision to refer replaced prescribing as the most important element of variable cost. No important relationships were discovered which linked cost generating activities with characteristics of the doctor or the practice. Implications for fund-holding are discussed.

Social indicators of health needs for general practice: a simpler approach

The ability of different measures of socioeconomic position to predict distress in a sample of general practice attenders has been examined. Perceived distress was measured using the Nottingham health profile. The measures of socioeconomic position included: social class, Jarman scores of patients' areas of residence, whether or not patients owned their own home, whether or not patients owned a car, whether or not they had been unemployed during the previous year and whether or not they had had further education. Social class data were only available for 84% of the 1075 respondents completing the Nottingham health profile. Those respondents for whom social class data were not available were significantly more likely to score positively on the social isolation, sleep and physical mobility dimensions of the Nottingham health profile. Not owning one's own home emerged as the measure of socioeconomic status that best predicted distress. The other measures of socioeconomic status that were significantly predictive of distress were not having had further education and having been unemployed during the last year. Different measures of socioeconomic position significantly predicted positive scores on different dimension of the Nottingham health profile. Although the Jarman score significantly predicted a positive score on the sleep dimension, it did not predict distress well when compared with the direct measures of disadvantage. There are simple, more direct measures of socioeconomic position than social class that could be collected routinely by practices which would form a better basis for the evaluation of services required to target those needs created by persisting social inequalities in health.(ABSTRACT TRUNCATED AT 250 WORDS)

Attitudes to medical care, the organization of work, and stress among general practitioners

Eighty five volunteer general practitioners in Lothian region recorded clinical and contextual information on 21,000 consultations during 1987-88. During their recording sessions they reported their perceived levels of stress using a previously validated scale. Subsequently, 80 of the doctors completed a previously validated multi-dimensional scale about their attitudes to patient care. Three attitude subscales (psychological orientation, appropriateness of consultations and responsibility for decisions) correlated with processes of care previously identified as indicators of good care. The 20 doctors who scored most highly on these patient-centred scales recorded self-perceived stress in 27% of their consultations compared with 11% of the consultations of the 33 doctors who scored lowest on these scales. Among the 20 most patient-centred doctors those booking patients at eight patients per hour or more reported stress at twice as many consultations as those with a longer booking interval; doctors whose preferred working styles conflicted with their booking patterns reported stress in up to 62% of consultations. Doctors with a higher patient-centred orientation find their work more stressful. Longer booking intervals remove much of that stress, particularly when doctors' preferred style of consulting requires them to spend more time at individual consultations. Previously described work stressors offer a theoretical explanation for a problem which is important for both doctors and patients.

A measure of perceived health in evaluating general practice: the Nottingham Health Profile

The paper describes two ways in which the Nottingham Health Profile (NHP) may be useful in evaluating general practice: it can provide useful and relevant information about the needs of patients, and can also be used to evaluate outcome by examining the relationship between changes in perceived health status before and 4 weeks after a consultation in relation to care received during that consultation. Findings are based on a sample of 1979 consulters who completed the Nottingham Health Profile prior to consultation and 732 consulters aged 16 years who also completed a Nottingham Health Profile 4 weeks after consultation. Comparisons are made according to the age, sex and illness status of the consulters, length of consultation and psychosocial care received. As a measure of need, significant differences were found in the health profile according to age, sex and illness status, length of consultation and doctors perception of the presence of relevant psychosocial issues. The only variable which was significantly related to short-term outcome was reported presence of a long term illness relevant to the consultation. The NHP is shown to have shortcomings as a measure of outcome for a cross-section of general practice consulters; it is, however, useful in demonstrating how processes of care relate to need in general practice.

Factors influencing waiting times and consultation times in general practice

Using data collected from 85 general practitioners in Lothian, large variations were found in the time patients wait for and spend with their doctor. This study, which sets consultations into their administrative framework, examines factors which cause this variation. Consultation time was found to be affected by the total number of patients attending a particular surgery, while waiting time was found to be affected by an individual patient's place within that surgery queue. Taking these two results together suggests that patients seen at the end of large surgeries are likely to get a different service from their doctor than they would have done earlier in the session, or when attending a less busy surgery. Possible strategies are discussed for reducing average waiting times, thereby decreasing the relative cost of consultation to patients.

Long to short consultation ratio: a proxy measure of quality of care for general practice

Eighty five general practitioners in the Lothian region recorded information on all surgery consultations on one day in every 15 for a year. On the basis of their mean consultation times with patients the working styles of the general practitioners were described as 'faster' (n = 24), 'intermediate' (n = 40) or 'slower' (n = 21). The 21,707 consultations which they carried out over this period were defined as 'short' (five minutes or less), 'medium' (six to nine minutes) or 'long' (10 minutes or more). Independent of doctor style, 'long' consultations as against 'short' consultations were associated with the doctor: (1) dealing with more of the psychosocial problems which had been recognized and were relevant to the patient's care; (2) dealing with more of the long term health problems which had been recognized as relevant; and (3) carrying out more health promotion in the consultation. Patients also reported greater satisfaction with longer consultations. The ratio of long:short consultations was found to be 0.28:1 for 'faster' doctors as against 2.3:1 for 'slower' doctors. When doctors in either group had more heavily booked surgeries or were running late, the long:short consultation ratio fell, in some cases by over 50%. This paper suggests that the ratio of long to short consultation length for a general practitioner might become the basis of a simply proxy measure of quality of care; and that its use might help monitor the effect of recent and proposed changes in the way in which general practice care is delivered.

Quality and the use of time in general practice: widening the discussion

To examine the association between different consulting styles in general practice (defined according to the average length of doctor-patient contact time in surgery consultations) and the process of care for those patients presenting with new episodes of respiratory illness, 1787 consultations conducted by 85 general practitioner principals in Lothian from November 1987 to May 1988 were analysed. Short as against long consultations resulted in less attention being given to psychosocial issues that the doctor recognised as relevant. When psychosocial problems were dealt with prescribing of antibiotics decreased. In this volunteer sample of doctors the process of care seemed to reflect decisions as to how time was allocated rather than inherently different patterns of clinical behavior. Organisational and contractual changes will shift the mix of financial and professional incentives for general practitioners in ways that could lead to doctors reallocating their time toward shorter consultations; such a reallocation could have important implications for patient care.

Effects of lactic acid infusions and pH on cerebral blood flow and metabolism

To determine the effects of lactic acidemia versus lactate on CBF, we infused lactic acid, either buffered with NaOH (L + NaOH) or with added NaCl (L + NaCl), to attain similar osmolalities in 18 piglets. CBF (microsphere technique), pH, blood gases, plasma osmolality, and cerebral arteriovenous differences of O2 content and lactic acid concentrations were measured prior to, at 30 min of a lactic acid infusion, and 15 and 90 min after completion of the infusion. Control arterial pH was comparable between groups (7.50 +/- 0.02 vs. 7.49 +/- 0.02, X +/- SE); during and following L + NaCl and L + NaOH, values were (p less than 0.05) 7.09 +/- 0.03, 7.35 +/- 0.02, and 7.46 +/- 0.02 vs. 7.58 +/- 0.03, 7.61 +/- 0.01, and 7.57 +/- 0.03, respectively. PaCO2 remained unchanged and osmolality rose by 15% in both groups during infusions and persisted throughout the study period. For L + NaCl piglets, CBF (ml/min.100 g) rose from 136 +/- 15 to 198 +/- 26 (p less than 0.05) at 30 min of infusion and remained elevated at 201 +/- 25 and 207 +/- 28 at 15 and 90 min following the infusion, respectively. Similarly, for L + NaOH piglets, CBF rose from 130 +/- 25 to 196 +/- 31 (p less than 0.05) with the infusion and was 174 +/- 17 and 166 +/- 21 at 15 and 90 min afterward, respectively. Although lactic acid infusion increases CBF, the associated metabolic acidemia is not responsible for changes in CBF.

Cerebral lactic acid delivery and uptake during and after ischemia in the piglet

To determine whether lactic acid is a cerebral substrate during and after partial ischemia in piglets, cerebral blood flow and arteriovenous differences of O2 and substrates were measured during control, after hemorrhagic hypotension, and 10 and 90 minutes after reperfusion with blood. During and following ischemia, alterations in cerebral O2 and glucose uptake indicated disturbed oxidative metabolism. Cerebral lactic acid uptake was similar at control, hypotension, and 90 minutes postreperfusion, but rose 10 minutes postreperfusion. Absent cerebral production of lactic acid during and net uptake following ischemia do not support lactic acid as a substrate since insufficient O2 was available for oxidation.

Measurement of stress as it affects the work of the general practitioner

This paper describes a preliminary study which collected information on the work of 18 general practitioners during a total of 52 days, and also recorded their feelings of pressure and stress from hour to hour throughout each day. The instruments used to record information on day-to-day activities and to measure self-perceived pressure, stress and arousal are described. The reliability and validity of the methods used are discussed, and some suggestions made for future development. A few preliminary findings are presented.

Marathon running and adverse weather conditions: a miscellany

This paper considers various predisposing and corrective factors for hypothermia and hyperthermia in marathon runners. It is concluded that a race should be cancelled or deferred if the forecast suggests that certain climatic thresholds are likely to be met or crossed.

Attendance at a breast screening clinic: a problem of administration or attitudes

In a study of why a sample of women, aged 45-64 and registered with a group practice in Edinburgh, attended or did not attend the Edinburgh Breast Screening Clinic demographic, aetiological, social, and perceptual characteristics of attenders and non-attenders were compared. Similar proportions of attenders and non-attenders knew the chance of a breast lump being cancer and were aware of the benefits of early diagnosis and treatment. The study, however, suggests that non-attenders saw the screening clinic as a place of risk while the attenders saw screening in a positive light: 79% of non-attenders as compared with 36% of attenders said that they were afraid of cancer being found, and most women attended either to reassure themselves that they had not got breast cancer or to receive early treatment if they had. Furthermore, 72% of non-attenders as compared with 13% of attenders were anxious that their lives would be disrupted if cancer were found at the screening clinic. There may well be an important irreducible element to non-attendance due to attitudinal factors; the ethical implications of attempting to eliminate this require careful consideration.

Anglo-French contrasts in medical practice

Medical practice in a British and French town was compared. The British and French general practitioners (GPs) and specialists were observed for one session each, and questionnaires were presented to the doctors and to samples of the inhabitants. Style of practice may largely determined by fiscal factors.