Understanding the factors that influence CT utilization for mild traumatic brain injury in a low resource setting - a qualitative study using the Theoretical Domains Framework

Introduction

In low resource settings (LRS), utilization of Computed Tomography scan (CTS) for mild traumatic brain injuries (mTBIs) presents unique challenges and considerations given the limited infrastructure, financial resources, and trained personnel. The Theoretical Domains Framework (TDF) offers a comprehensive theoretical lens to explore factors influencing the decision-making to order CTS for mTBI by imaging referrers (IRs).

Objectives

The primary objective was to explore IRs' beliefs about factors influencing CT utilization in mTBIs using TDF in Uganda.Differences in the factors influencing CTS ordering behavior across specialties, levels of experience, and hospital category were also explored.

Materials and Methods

In-depth semi-structured interviews guided by TDF were conducted among purposively selected IRs from 6 tertiary public and private hospitals with functional CTS services. A thematic analysis was performed with codes and emerging themes developed based on the TDF.

Results

Eleven IRs including medical officers, non-neurosurgeon specialists and neurosurgeons aged on average 42 years (SD+/-12.3 years) participated.Identified factors within skills domain involved IRs' clinical assessment and decision-making abilities, while beliefs about capabilities and consequences encompassed their confidence in diagnostic abilities and perceptions of CTS risks and benefits. The environmental context and resources domain addressed the availability of CT scanners and financial constraints. The knowledge domain elicited IRs' understanding of clinical guidelines and evidence-based practices while social influences considered peer influence and institutional culture. For memory, attention & decision processes domain, IRs adherence to guidelines and intentions to order CT scans were cited.

Conclusion

Using TDF, IRs identified several factors believed to influence decision making to order CTS in mTBI in a LRS. The findings can inform stakeholders to develop targeted strategies and evidence-based interventions to optimize CT utilization in mTBI such as; educational programs, workflow modifications, decision support tools, and infrastructure improvements, among others.

Acceptability of a Randomized Trial of Anti-depressant Medication or Interpersonal Therapy for Treatment of Perinatal Depression in Women with HIV

Postpartum depression (PPD) affects nearly 20% of postpartum women in Sub-Saharan Africa (SSA), where HIV prevalence is high. Depression is associated with worse HIV outcomes in non-pregnant adults and mental health disorders may worsen HIV outcomes for postpartum women and their infants. PPD is effectively treated with psychosocial or pharmacologic interventions; however, few studies have evaluated the acceptability of treatment modalities in SSA. We analyzed interviews with 23 postpartum women with HIV to assess the acceptability of two depression treatments provided in the context of a randomized trial. Most participants expressed acceptability of treatment randomization and study visit procedures. Participants shared perceptions of high treatment efficacy of their assigned intervention. They reported ongoing HIV and mental health stigma in their communities and emphasized the importance of social support from clinic staff. Our findings suggest a full-scale trial of PPD treatment will be acceptable among women with HIV in Zambia.

Implementation of a fast triage score for patients arriving to a low resource hospital in Uganda

Background

The Kitovu Fast Triage (KFT) score predicts imminent mortality from mental status, gait and either respiratory rate or oxygen status. As some non-life-threatening conditions require immediate attention, the South African Triage System (SATS) assigns arbitrary rankings of urgency for specific patient presentations.

Aim

Establish the feasibility of determining and then comparing the KFT score and explicitly defined SATS urgency rankings.

Methods

A computerized proforma used standardized methods of assessing and measuring mental status and gait, and respiratory rate and collected explicitly defined clinical presentations and SATS urgency rankings on 4,842 patients at the time of their arrival to the hospital.

Results

75 % of patients were awake and able to count the months backwards from December to September. Respiratory rates measured by a computer application had no clustering of values or digit preference; however, oximetry failed in 14 % of patients, making the score based on respiratory rate the most practical in our setting. Determining the SATS acuity ranking and both KFT scores usually took <90 s; the commonest complaints were pain, dyspnoea, and fever, which often occurred together; overall 3574 (73.8 %) patients had at least one of these symptoms as did 96.4 % of those with the highest KFT score based on respiratory rate. 12 % of patients with the lowest KFT score based on respiratory rate had one or more very urgent SATS rankings, 52 % of whom had non-severe chest pain. Only 5.7 % of patients complaining of fever had a temperature >38 °C.

Conclusion

Whilst the KFT score based on respiratory rate could be rapidly determined in all patients, it identified some patients as low acuity who had very urgent SATS rankings. However, most of these patients had non-severe chest pain, which may not be a very urgent presentation in our setting as ischaemic heart disease remains uncommon in sub-Saharan Africa.

Building capacity for point of care alcohol-based handrub (ABHR) and hand hygiene compliance among health care workers in the rural maternity and surgical units of a hospital in Cameroon

BACKGROUND

Hand hygiene (HH) is challenging in health care, but particularly in resource-limited settings due to a lack of training, resources, and infrastructure. This study aimed to evaluate the implementation of wall-mounted alcohol-based handrub (ABHR) at the point of care (POC) on HH compliance among health care workers in a Cameroon hospital.

METHODS

It was a three-stage before and after study. The first stage involved baseline collection of ABHR utilization and HH compliance data. The second stage included the implementation of ABHR at the POC, supported by an implementation strategy involving HH training, monitoring and feedback, and HH champions. The third stage involved postimplementation data collection on ABHR use and HH compliance.

RESULTS

5,214 HH opportunities were evaluated. HH compliance significantly increased from 33.3% (baseline) to 83.1% (implementation stage) (P < .001) and to 87.2% (postimplementation stage) (P < .001). Weekly ABHR usage increased significantly during implementation (5,670 ml), compared to baseline, (1242.5 ml, P = .001), and remained high in postimplementation (7,740 ml).

CONCLUSIONS

Continuous availability of ABHR at POC, supported by implementation strategy, significantly increased HH compliance and ABHR use. Learning from this study could be used to implement ABHR at POC in other facilities.

Establishing a novel partnership model to deploy health services for children with autism in a low-resource setting - experience from Sri Lanka

Sri Lanka is representative of challenges faced by low-income and middle-income countries, including the rise in the prevalence of autism and the lack of sufficient autism-specific services in the state sectors. The experience in establishing a Center to provide services for children with autism in Northern Sri Lanka is described. Funding and resourcing were accessed through an innovative partnership-based public/non-governmental organisation/charity model, where service-based outcomes were the main objectives. This model, incorporating state institutions, local and international charity organisations, and volunteers, devised a bespoke approach to care provision using the available resources under the clinical supervision of a consultant psychiatrist and the administrative purview of the Regional Director of Health Services. The evolution of this Center into a Learning Health System is described, reflecting how a minimalistic partnership approach focused on the integration of existing organisations and services could be a feasible model for the delivery of high-quality healthcare in low-resource settings.

Factors associated with conversion in laparoscopic surgery in a low-resource setting: a single-center prospective study

INTRODUCTION

Laparoscopy has a clear patient benefit related to postoperative morbidity but may not be as commonly performed in low-and middle-income countries. The decision to convert to laparotomy can be complex and involve factors related to the surgeon, patient, and procedure. The objective of this work is to analyze the factors associated with conversion in laparoscopic surgery in a low-resource setting.

METHODS

This is a single-center prospective study of patients who underwent laparoscopic surgery between May 1, 2018 and October 31, 2021. The parameters studied were age, sex, body mass index (BMI), intraoperative complication (e.g., accidental enterotomy, hemorrhage), equipment malfunction (e.g., technical failure of the equipment, break in CO2 supply line), operating time, and conversion rate.

RESULTS

A total of 123 laparoscopic surgeries were performed. The average age of patients was 31.2 years (range 11-75). The procedures performed included appendix procedures (48%), followed by gynecological (18.7%), gallbladder (14.6%), digestive (10.56%), and abdominal procedures (4%). The average length of hospitalization was 3 days (range 1-16). Conversion to laparotomy was reported in 8.9% (n = 11) cases. Equipment malfunction was encountered in 9.8% (n = 12) cases. Surgical complications were noted in 11 cases (8.9%). Risk factors for conversion were shown to be BMI > 25 kg/m2 (OR 4.6; p = 0.034), intraoperative complications (OR 12.6; p = 0.028), and equipment malfunction (OR 9.4; p = 0.002).

CONCLUSION

A better understanding of the underlying factors associated with high conversion rates, such as overweight/obesity, intraoperative complications, and equipment failure, is the first step toward surgical planning to reduce postoperative morbidity in low-resource settings.

Nasopharyngeal Carcinoma in Childhood: Evidence of a Malfunctioning Oncology Ecosystem: A Case Series from a Low Resource Setting

Nasopharyngeal carcinoma (NPC) refers to malignancy arising from the epithelium of the nasopharynx. It is a rare tumor globally but seen in higher prevalence in certain populations associated with the endemicity of Epstein- Barr Virus. It is usually seen in clinical settings in developing countries in late stages majorly due to poor health-seeking behavior, healthcare costs, and misdiagnosis arising from its vague and ambiguous symptoms. The outcome of NPC depends strongly on the stage at diagnosis and access to the right treatment which may prove challenging in low-resource settings where care is paid for out of pocket. We report three cases of nasopharyngeal carcinoma, its presentation, and a brief review of the literature on its epidemiology, histologic types, and outcomes in the peadiatric population.

International Health Electives: defining learning outcomes for a unique experience

BACKGROUND

An International Health Elective (IHE) can be a unique learning experience for students. However, it has proven difficult to clearly define learning outcomes that capture the complexity of an IHE and are aligned with future professional performance. This study aimed to further define learning outcomes for IHEs in low- to middle-income countries (LMIC) from a student perspective.

METHODS

We conducted a deductive analysis of pre-departure and post-elective reflective reports of fifth-year medical students who participated in an IHE as part of their program. This provided possible learning objectives that were further explored in semi-structured individual interviews with medical students who had recently returned from an IHE.

RESULTS

We analyzed 33 reports of students participating in an IHE from 2017-2019 and held 19 interviews. Thematic analysis revealed 9 themes: developing intercultural competence, developing appreciation for differences in health care delivery systems, understanding international health, understanding the global burden of disease, developing a career perspective, developing clinical skills in resource low settings, becoming cost conscious, developing social responsibility and self-actualization.

CONCLUSIONS

We identified 9 learning outcomes that are directly and indirectly related to clinical practice. They add to the on-going discourse on the benefits of IHEs. These outcomes can be further developed by investigating the perspectives of home and host supervisors and educationalists, while taking the local context into account. Follow-up studies can evaluate to what extend these outcomes are achieve during an IHE.

Preservation of Streptococcus pneumoniae quality control strains using chocolate agar blocks in glycerol at minus 70 degrees celsius

We present a method for storage of the quality control strain of S. pneumoniae that could be used in low resource settings. Small blocks of chocolate agar with growth were placed in glycerol (60%V/V) and stored at minus 70 °C. Viability and cultural characteristics were maintained for the testing period of 10 months. The wide availability of both chocolate agar and glycerol make this a suitable alternative to other specialized formulations usually used to maintain stocks of S. pneumoniae ATCC 49619 strain required for quality control of susceptibility testing.

Learn, Engage, Act, Dedicate (LEAD): development and feasibility testing of a task-shifted intervention to improve alcohol use, depression and family engagement for fathers

BACKGROUND

Men's depression, alcohol use, and family problems commonly co-occur to create of cluster of mental health problems. Yet, few treatments exist to address these problems, especially in low and middle-income countries (LMICs). This paper describes the development and initial feasibility and acceptability of a novel task-shifted intervention to address this cluster of men's mental health problems with a focus on engaging and retaining men in treatment.

METHODS

The intervention, Learn, Engage, Act, Dedicate (LEAD), is based in behavioral activation blended with motivational interviewing and was pilot tested in Kenya. To develop LEAD, we engaged in a community-engaged multi-step, collaborative process with local Kenyan stakeholders. LEAD was piloted with nine fathers reporting problem drinking. To assess initial feasibility and acceptability, recruitment and participation were tracked and descriptive statistics were generated given engagement of men was key for proof of concept. Semi-structured interviews were conducted with participants and analyzed using thematic content analysis.

RESULTS

The development process resulted in a weekly 5-session intervention rooted in behavioral activation, motivational interviewing, and masculinity discussion strategies. These approaches were combined and adapted to fit contextually salient constructs, such as the importance of the man as provider, and streamlined for lay providers. Feasibility and acceptability results were promising with high attendance, acceptability of delivery and intervention content, and perceived intervention helpfulness.

CONCLUSION

Results describe an acceptable task-shifted treatment that may engage men in care and addresses a cluster of common mental health problems among men in ways that consider social determinants like masculinity. Findings set the stage for a larger trial. Trial registration ISRCTN, ISRCTN130380278. Registered 7 October 2019-Retrospectively registered, http://www.isrctn.com/ISRCTN13038027.

Training needs assessment for practicing pediatric critical care nurses in Malawi to inform the development of a specialized master's education pathway: a cohort study

Background

Significant improvements in under-five mortality in Malawi have been demonstrated over the past thirty years; however, Malawian healthcare remains with gaps in availability and access to quality pediatric critical care nursing training and education. To improve expertise of pediatric critical care nurses in Malawi, Kamuzu University of Health Sciences (KUHeS), Queen Elizabeth Central Hospital (QECH), and Mercy James Center (MJC) entered a partnership with Seed Global Health, a US non-governmental organization. A needs assessment was conducted to understand the training needs of nurses currently working in pediatric critical care and in preparation for the development of a specialized Master’s in Child Health pathway in Pediatric Critical Care (PCC) Nursing at KUHeS.

Methods

The needs assessment was completed using a survey questionnaire formatted using an ABCDE (Airway, Breathing, Circulation, Disability, and Exposure) framework. The questionnaire had Likert scale and yes/no questions. Data was manually entered into excel and was analyzed using descriptive statistics.

Results

One hundred and fifty-three nurses at QECH and MJC responded to the survey. Most nurses were between the ages of 25 and 35 years (N = 98, 64%), female (N = 105, 69%), and held either a Bachelors (N = 72, 47%) or diploma (N = 70, 46%) in nursing. Nurses had high rates of confidence in certain skills: airway management (N = 120, 99%), breathing assessment & management (N = 153, 100%). However, nurses demonstrated little to no confidence in areas such as: mechanical ventilation (N = 68, 44%), ECG evaluation (N = 74, 48%), and arterial blood gas collection & interpretation (N = 49, 32%).

Conclusion

It is important to identify priority areas for training and skills development to address in the PCC master’s within the child health pathway at KUHeS. Ideally this partnership will produce practice-ready PCC nurses and will establish a recognized PCC nursing workforce in Malawi.

Qualitative exploration of feasibility and acceptability of the modified Atkins diet therapy for children with drug resistant epilepsy in Kenya

PURPOSE

Approximately one-third of children with epilepsy have clinical syndromes characterized by drug resistance. Modified Atkins dietary therapy (MADT) can reduce seizures and improve health outcomes for these children. This intervention is yet to be consistently offered as standard of care in sub-Saharan Africa.

OBJECTIVES

This study aimed to assess feasibility and acceptability of MADT for children with drug-resistant epilepsy and identify enabling strategies for implementation and adherence to the MADT.

METHODS

This qualitative inquiry utilized in-depth interviews with purposively selected caregivers and adolescent patients having used MADT for drug-resistant epilepsy. A qualified team consisting of a social scientist and an interviewer carried out the interviews with consenting participants. Thematic analysis was done independent of the clinicians.

RESULTS

This study enrolled 17 participants including 14 caregivers of children aged 1-17 years, and three adolescents. Caregivers were predominantly trained professionals living in urban areas who had attended the epilepsy clinic for at least one year. Duration of continuous MADT use ranged from two weeks to two years. Among participants who indicated that they could afford to provide the MADT, it was less costly to provide for younger children and for those living in rural areas. At the time of the study, majority of the caregivers had ceased administration of the MADT, more than half of whom reported barriers including cost of food, child refusal of foods, and inconsistent dietician support. Social support was a key enabler to successful implementation and continuation of the diet. Majority of the participants considered MADT to be an effective and acceptable intervention for management of epilepsy.

CONCLUSIONS

Among participants in this focused Kenyan group, implementation of MADT was found to be feasible particularly for younger children living in rural areas. Majority of participants evaluated MADT to be an effective and acceptable intervention for management of epilepsy. Cultural factors did not influence feasibility or acceptability of MADT in this study.

Needs of early adopters in supporting a nursing curriculum innovation in a low resource setting: An exploratory case study

AIM

This paper aims to take a critical look at the introduction of one curriculum innovation, driven by a case study example of the implementation of a competency-based curriculum for an undergraduate nursing programme in a low-resource context, and the subsequent impact on the educators expected to implement it.

BACKGROUND

In low-resource contexts opportunities for faculty development related to sustaining newly implemented curriculum models are scarce. Early adopters of a curriculum innovation bear the potential of supporting other educators in implementing and sustaining a curriculum innovation.

METHODS

Through an exploratory qualitative case study design we interviewed early adopters of a curriculum innovation on their needs in supporting other educators. Semi-structured interviews explored their experience and needs related to mentoring other educators in their institutions. The collected data were then transcribed and thematically analysed through various coding methods. Themes from this analysis are presented as the outcome of this study.

RESULTS

Resources and structured approaches to educator support were identified as needs by early adopters. They further described challenges in implementing the new curriculum and the poor monitoring of the programme.

CONCLUSION

This study raises questions on the sustainability of curriculum innovations especially in low income countries and the role of short-term single investments on long term outputs. Early adopters need to be enabled and supported in their role for optimal return on investment.

Clinical effectiveness of gasless laparoscopic surgery for abdominal conditions: systematic review and meta-analysis

BACKGROUND

In high-income countries, laparoscopic surgery is the preferred approach for many abdominal conditions. Conventional laparoscopy is a complex intervention that is challenging to adopt and implement in low resource settings. This systematic review and meta-analysis evaluate the clinical effectiveness of gasless laparoscopy compared to conventional laparoscopy with CO₂ pneumoperitoneum and open surgery for general surgery and gynaecological procedures.

METHODS

A search of the MEDLINE, EMBASE, Global Health, AJOL databases and Cochrane Library was performed from inception to January 2021. All randomised (RCTs) and comparative cohort (non-RCTs) studies comparing gasless laparoscopy with open surgery or conventional laparoscopy were included. The primary outcomes were mortality, conversion rates and intraoperative complications.

SECONDARY OUTCOMES

operative times and length of stay. The inverse variance random-effects model was used to synthesise data.

RESULTS

63 studies were included: 41 RCTs and 22 non-RCTs (3,620 patients). No procedure-related deaths were reported in the studies. For gasless vs conventional laparoscopy there was no difference in intraoperative complications for general RR 1.04 [CI 0.45-2.40] or gynaecological surgery RR 0.66 [0.14-3.13]. In the gasless laparoscopy group, the conversion rates for gynaecological surgery were high RR 11.72 [CI 2.26-60.87] when compared to conventional laparoscopy. For gasless vs open surgery, the operative times were longer for gasless surgery in general surgery RCT group MD (mean difference) 10 [CI 0.64, 19.36], but significantly shorter in the gynaecology RCT group MD - 18.74 [CI - 29.23, - 8.26]. For gasless laparoscopy vs open surgery non-RCT, the length of stay was shorter for gasless laparoscopy in general surgery MD - 3.94 [CI - 5.93, - 1.95] and gynaecology MD - 1.75 [CI - 2.64, - 0.86]. Overall GRADE assessment for RCTs and Non-RCTs was very low.

CONCLUSION

Gasless laparoscopy has advantages for selective general and gynaecological procedures and may have a vital role to play in low resource settings.

Five-year overall survival following chemoradiation therapy for locally advanced cervical carcinoma in women living with and without HIV infection in Botswana

Purpose

To compare updated prospective 5-year survival outcomes of cervical cancer patients living with and without human immunodeficiency virus (HIV) infection who initiated curative chemoradiation therapy (CRT) in a resource-limited setting.

Methods & Materials

Women in Botswana with locally advanced cervical cancer were enrolled in a prospective, observational, cohort study from July 2013 through January 2015. Survival outcomes were analyzed after 5 years of follow-up.

Results

This cohort included 143 women initiating curative CRT. Sixty-seven percent (n = 96) of cohort were women living with HIV (WLWH), all of whom were receiving antiretroviral therapy (ART) at the time of treatment initiation and boasted a median CD4 count of 481 cells/μL (IQR, 351-579 μL). The 5-year overall survival (OS) rates were 56.8% (95% CI, 40.0–70.5%) for patients without HIV infection and 55.1% (95% CI, 44.2–64.7%) for WLWH (p = 0.732). Factors associated with superior 5-year OS on multivariate analyses included baseline hemoglobin > 10 g/dL (hazard ratio (HR) 0.90, 95% CI, 0.83–0.98, p = 0.015), lower stage at diagnosis (stage I and II vs. III and IV) (HR 1.39, 95% CI 1.09–1.76, p = 0.007), and higher EQD2 (HR 0.98, 95% CI 0.97–0.99, p = 0.001).

Conclusions

Five-year OS was not impacted by HIV status in this population of WLWH with well-managed infection who initiated curative treatment for cervical cancer in Botswana. Regardless of HIV status, hemoglobin levels and stage at diagnosis were associated with survival. These findings suggest that treatment for cervical cancer in WLWH with well-controlled infection need not be altered solely due to HIV status.

Ventricular noncompaction and long QT syndrome - A deadly double hit for the foetus

Congenital long QT syndrome [LQTS] is a channelopathy characterized by QT prolongation and polymorphic VT. LQTS however need not be a purely electrical disease. Defects in ion channels may cause myocardial architectural disruption leading to ventricular non compaction [VNC]. It is defined as the presence of prominent ventricular trabeculations and deep intertrabecular recesses within the endomyocardium. We describe the in-utero management of a foetus who was later found to have LQTS with VNC. The detection of ventricular tachycardia and complete heart block in utero should arouse the suspicion of LQTS. It would be wise to avoid QT prolonging antiarrhythmics in this subset of patients.

Two simple replacements for the Triage Early Warning Score to facilitate the South African Triage Scale in low resource settings

BACKGROUND

The South African Triage Scale (SATS) requires the calculation of the Triage Early Warning Score (TEWS), which takes time and is prone to error.

AIM

to derive and validate triage scores from a clinical database collected in a low-resource hospital in sub-Saharan Africa over four years and compare them with the ability of TEWS to triage patients.

METHODS

A retrospective observational study carried out in Kitovu Hospital, Masaka, Uganda as part of an ongoing quality improvement project. Data collected on 4482 patients was divided into two equal cohorts: one for the derivation of scores by logistic regression and the other for their validation.

RESULTS

Two scores identified the largest number of patients with the lowest in-hospital mortality. A score based on oxygen saturation, mental status and mobility had a c statistic for discrimination of 0.83 (95% CI 0.079-0.87) in the derivation, and 0.81 (95% CI 0.77-0.86) in the validation cohort. Another score based on respiratory rate, mental status and mobility had a c statistic of 0.82 (95% CI 0.078-0.87) in the derivation, and 0.81 (95% CI 0.77-0.86) in the validation cohort. The oxygen saturation-based score of zero points identified 51% of patients in the derivation cohort who had in-hospital mortality rate of 0.5%, and 49% of patients in the validation cohort who had in-hospital mortality of 1.0%. A respiratory rate-based score of zero points identified 45% in the derivation cohort who had in-hospital mortality rate of 0.5%, and 44% of patients in the validation cohort who had in-hospital mortality of 0.8%. Both scores had comparable performance to TEWS.

CONCLUSION

Two easy to calculate scores have comparable performance to TEWS and, therefore, could replace it to facilitate the adoption of SATS in low-resource settings.

The impact of introducing ambulance and delivery fees in a rural hospital in Tanzania

Background

Access to health care facilities is a key requirement to enhance safety for mothers and newborns during labour and delivery. Haydom Lutheran Hospital (HLH) is a regional hospital in rural Tanzania with a catchment area of about two million inhabitants. Up to June 2013 ambulance transport and delivery at HLH were free of charge, while a user fee for both services was introduced from January 2014. We aimed to explore the impact of introducing user fees on the population of women giving birth at HLH in order to document potentially unwanted consequences in the period after introduction of fees.

Methods

Retrospective analysis of data from a prospective observational study. Data was compared between the period before introduction of fees from February 2010 through June 2013 and the period after from January 2014 through January 2017. Logistic regression modelling was used to construct risk-adjusted variable-life adjusted display (VLAD) and cumulative sum (CUSUM) plots to monitor changes.

Results

A total of 28,601 births were observed. The monthly number of births was reduced by 17.3% during the post-introduction period. Spontaneous vaginal deliveries were registered less frequently with a decrease of about 17/1000 births in non-cephalic presentations. Labour complications and caesarean sections increased with about 80/1000 births. There was a reduction in newborns with birth weight less than 2500 g. The observed changes were stable over time. For most variables, a significant change could be detected after a few weeks.

Conclusion

After the introduction of ambulance and delivery fees, an increase in labour complications and caesarean sections and a decrease in newborns with low birthweight were observed. This might indicate that women delay the decision to seek skilled birth attendance or do not seek help at all, possibly due to financial reasons. Lower rates of births in a safe health care facility like HLH is of great concern, as access to skilled birth attendance is a key requirement in order to further reduce perinatal mortality. Therefore, free delivery care should be a high priority.

Prone during pandemic: development and implementation of a quality-based protocol for proning severe COVID-19 hypoxic lung failure patients in situationally or historically low resource hospitals

Background

Intermittent Prone Positioning (IPP) for Acute Respiratory Distress Syndrome (ARDS) decreases mortality. We present a program for IPP using expedient materials for settings of significant limitations in both overwhelmed established ICUs and particularly in low- and middle-income countries (LMICs) treating ARDS due to COVID-19 caused by SARS CoV-2.

Methods

The proning program evolved based on the principles of High Reliability Organizations (HROs) and Crew Resource Management (CRM). Patients with severe ARDS [PaO₂:FiO₂ ratio (PFr) ≤ 150 on FiO₂ ≥ 0.6 and PEEP ≥ 5 cm H₂O] received IPP. Patients were placed prone 16 h each day. When PFr was ≥ 200 for > 8 h supine IPP ceased. IPP used available materials without requiring additional work from the bedside team. Changes in PFr, PaCO₂, and the SaO₂:FiO₂ ratio (SaFr) positionally were evaluated using t-statistics and ANOVA with Bonferroni correction (p < 0.017).

Results

Between 14APR2020 and 09MAY2020, at the peak of deaths in New York, there were 202 IPPs in 29 patients. Patients were 58.5 ± 1.7 years of age (37, 73), 76% male and had a body mass index (BMI) of 27.8 ± 0.8 (21, 38). Pressor agents were used in 76% and 17% received dialysis. The PFr prior to IPP was 107.5 ± 5.6 and 1 h after IPP was 155.7 ± 11.2 (p < 0.001 compared to pre-prone). PFr after the patients were placed supine was 131.5 ± 9.1 (p = 0.02). Pre-prone PaCO₂ was 60.0 ± 2.5 and the 1-h post-prone PaCO₂ was 67.2 ± 3.1 (p = 0.02). Supine PaCO₂ after IPP was 60.4 ± 3.4 (p = 0.90). The SaFr prior to IPP was 121.3 ± 4.2 and the SaFr 1 h after positioning was 131.5 ± 5.1 (p = 0.03). The post-IPP supine SaFr was 139.7 ± 5.9 (p < 0.001). With ANOVA and Bonferroni correction there were statistically significant changes in PFr (p < 0.001) and SaFr (p < 0.001) and no significant changes in PaCO₂ over the four time points measured. Using regression coefficients, the SaFrs predicted by PFrs of 150 and 200 at baseline are 133.2 and 147.3, respectively.

Conclusions

An IPP program for patients with COVID-19 ARDS can be instituted rapidly, safely, and effectively during an overwhelming mass casualty scenario. This approach may be equally applicable in both traditionally austere environments in LMICs and in otherwise capable centers facing situational resource limitations.

Successful use of an improvised bubble CPAP device for severe respiratory distress caused by pulmonary tuberculosis

Introduction

This case report discusses the successful use of an improvised bubble continuous positive airway pressure (CPAP) apparatus made using items commonly available in a poorly resourced district hospital.

Case presentation

A 64-year-old female with no co-morbidities presented with respiratory failure due to pulmonary tuberculosis and was not accepted into the regional Intensive Care Unit (ICU) on referral. She required 8 days of improvised bubble CPAP to maintain adequate oxygen saturation before weaning and eventual discharge.

Discussion

Improvised bubble CPAP is commonly used in neonatal care in developing countries and well described in literature however, there are no reports of its successful use in adult patients. In the absence of access to ICU or other Non-invasive ventilation (NIV) equipment, improvised bubble CPAP may provide some therapeutic benefit.

Proposed guidelines for screening of hyperglycemia in patients hospitalized with COVID-19 in low resource settings

BACKGROUND AND AIMS

The coronavirus disease 2019 (COVID-19) pandemic has immensely strained healthcare systems worldwide. Diabetes has emerged as a major comorbidity in a large proportion of patients infected with COVID-19 and is associated with poor health outcomes. We aim to provide a practical guidance on screening of hyperglycemia in persons without known diabetes in low resource settings.

METHODS

We reviewed the available guidelines on this subject and proposed an algorithm based on simple measures of blood glucose (BG) which can be implemented by healthcare workers with lesser expertise in low resource settings.

RESULTS

We propose that every hospitalized patient with COVID-19 infection undergo a paired capillary BG assessment (pre-meal and 2-h post-meal). Patients with pre-meal BG < 7.8 mmol/L (140 mg/dL) and post-meal BG < 10.0 mmol/L (180 mg/dL) may not merit further monitoring. On the other hand, those with one or more value above these thresholds should undergo capillary BG monitoring (pre-meals and 2 hours after dinner) for the next 24 hours. When two or more (≥50%) such values are significantly elevated [pre-meal ≥8.3 mmol/L (150 mg/dL) and post-meal ≥11.1 mmol/L (200 mg/dL)], pharmacotherapy should be immediately initiated. On the other hand, in patients with modest elevation of one or more values [pre-meal 7.8-8.3 mmol/L (140-150 mg/dL) and post-meal 10.0-11.1 mmol/L (180-200 mg/dL)], dietary modifications should be initiated and pharmacotherapy considered only if BG control remains suboptimal.

CONCLUSION

We highlight strategies for screening of hyperglycemia in persons without known diabetes treated for COVID-19 infection in low resource settings. This guidance may well be applied to other settings in the near future.

A Comparative Study of Two Infant Feeding Tools: The Nifty Cup and The Paladai

OBJECTIVE

The World Health Organization recommends that infants unable to feed directly at the breast in low resource settings be cup fed with hand expressed breastmilk. No standard feeding cup exists. The aim of this study was to evaluate the design of the Nifty cup, a newly designed feeding cup, as compared to the paladai and to assess acceptability among mothers and health care providers.

METHODS

This study was conducted at Sri Ramachandra Medical Center and Research Institute in Chennai. Eligible caregivers were primary caregivers of infants who were less than 12 mo old, born prematurely or with an oral cleft, and who were fed by cup. Health care providers who prescribed cup feeding for infants at least 4 times in the past year were also eligible. Caregivers and health care providers fed each infant with a paladai and a Nifty cup. They completed an interviewer-administered survey. The design and acceptability parameters of the Nifty cup were compared to those of paladai using a Wilcoxon signed rank test.

RESULTS

Forty three caregivers and 28 health care providers were enroled. Among caregivers, the Nifty cup as compared to the paladai was less problematic on most parameters including spillage, regurgitation, difficulty in use, and duration of feeding (all p-values <0.01). Findings were similar for health care providers.

CONCLUSIONS

The Nifty cup is a promising feeding cup for feeding infants with breastfeeding difficulties to support growth and nutrition.

Improving standard of pediatric surgical care in a low resource setting: the key role of academic partnership

Background

An epidemiological transition is interesting Sub-Saharan Africa increasing the burden of non-communicable diseases most of which are of surgical interest. Local resources are far from meeting needs and, considering that 50% of the population is less than 14 years of age, Pediatric surgical coverage is specially affected. Efforts are made to improve standards of care and to increase the number of Pediatric surgeons through short-term specialist surgical Missions, facilities supported by humanitarian organization, academic Partnership, training abroad of local surgeons. This study is a half term report about three-years Partnership between the University of Chieti- Pescara, Italy and the University of Gezira, Sudan to upgrade standard of care at the Gezira National Centre for Pediatric Surgery (GNCPS) of Wad Medani. Four surgical Teams per year visited GNCPS. The Program was financed by the Italian Agency for Development Cooperation.

Methods

The state of local infrastructure, current standard of care, analysis of caseload, surgical activity and results are reported. Methods utilized to assess local needs and to develop Partnership activities are described.

Results

Main surgical task of the visiting Team were advancements in Colorectal procedures, Epispadias/Exstrophy Complex management and Hypospadias surgery (20% of major surgical procedures at the GNCPS). Intensive care facilities and staff to assist more complex cases (i.e. neonates) are still defective. Proctoring, training on the job of junior surgeons, anaesthetists and nurses, collaboration in educational programs, advisorship in hospital management, clinical governance, maintenance of infrastructure together with training opportunities in Italy were included by the Program. Despite on-going efforts, actions have not yet been followed by the expected results. More investments are needed on Healthcare infrastructures to increase health workers motivation and prevent brain drain.

Conclusions

The key role that an Academic Partnership can play, acting through expatriated Teams working in the same constrained contest with the local workforce, must be emphasized. Besides clinical objectives, these types of Global Health Initiatives address improvement in management and clinical governance. The main obstacles to upgrade standard of care and level of surgery met by the Visiting Team are scarce investments on health infrastructure and a weak staff retention policy, reflecting in poor motivation and low performance.

Integrated cervical cancer screening in Mayuge District Uganda (ASPIRE Mayuge): a pragmatic sequential cluster randomized trial protocol

Background

Cervical cancer is almost entirely preventable through vaccination and screening, yet remains one of the ‘gravest threats to women’s lives’ according to the World Health Organization. Specific high-risk subtypes of human papillomavirus (HR-HPV) are well-established as the primary cause of cervical cancer. Uganda has one of the highest cervical cancer incidence rates in the world (54.8 per 100,000) as a result of limited screening access and infrastructure. The integration of a self-collected cervical cancer screening program using HPV testing within existing community-based primary health care services could increase access to screening and reduce cervical cancer rates among Ugandan women.

Methods

Using a pragmatic, sequential, cluster randomized trial design; we will compare the effectiveness of two cervical cancer screening models for self-collected HPV testing: 1) community health worker recruitment (door-to-door); and 2) community health meetings. In Mayuge district, Uganda, 31 villages are randomized to one of two treatment arms. Due to the nature of this trial, blinding is not possible. Women are eligible to participate if they have no previous history of hysterectomy or treatment for cervical cancer or pre-cancer and are aged 25–49 years old. All participants receive an integrated package of cervical cancer screening and education. Samples are tested for HPV using GeneXpert point of care testing. All women who test positive for HR-HPV types are referred to a designated health centre for follow-up inspection by Visual Inspection with Acetic acid (VIA) and treatment with thermal ablation. The primary outcome for the trial is the number of women who attend follow-up for VIA screening at a designated Health Centre after a positive HR-HPV test out of all women screened per arm. Secondary outcomes include: cervical cancer screening knowledge; patient-reported experience measures for self-collected cervical cancer screening; and HPV incidence.

Discussion

Results from this study will inform the national scale-up of cervical cancer screening in Uganda, aligning with the World Health Organization’s target of achieving cervical cancer elimination through the pillar of increased HPV screening coverage.

Trial registration

ISRCTN, ISRCTN12767014. Registered 14 May 2019, 10.1186/ISRCTN12767014; clinicaltrials.gov, NCT04000503; Registered 27 June 2019, https://clinicaltrials.gov/ct2/show/NCT04000503

Protocol version

January 8, 2020, version 1.

Perceptions, expectations and challenges among men during in vitro fertilization treatment in a low resource setting: a qualitative study

Introduction

Partner support is very important in alleviating the burden of infertility related stress and although understudied, partner coping patterns also play a key role in the other partner’s ability to cope with the infertility experience which eventually affects treatment outcomes. Very few studies more so in a low to middle income setting, explore the psychological and social aspects of infertility in men. There is a need for a deeper understanding into men’s perceptions, expectations and challenges of fertility treatment in our low resource setting.

Objective

To explore men’s perceptions, expectations, challenges and experiences during IVF treatment among men in a low resource setting.

Methods

A qualitative research design was utilised. The study was conducted at life sure fertility and gynaecology centre. The study participants were men participating in the IVF cycles. They were selected purposefully by maximum variation sampling. All the interviews took place on the day of enrolment for treatment and inductive content analysis was used to draw meaning from the transcripts. Ethical approval for the study will be sought from Nsambya Hospital IRB/REC.

Results

Seven major themes arose, and these included: (1) Societal influence on IVF treatment experience; (2) Social support during IVF treatment; (3) Feeling insignificant; (4) Financial burden; (5) IVF as an emotional bridge; (6) Inadequate sensitization; (7) Fear of treatment failure.

Conclusion

Men’s experiences during IVF treatment were negatively affected by the society’s perceptions of IVF treatment and infertility, cost of treatment, perceived men’s involvement and insufficient knowledge about the IVF process. However, spouse and friends’ support helped with coping and the IVF treatment experience strengthened emotional bonds.

Electronic supplementary material

The online version of this article (10.1186/s40738-019-0058-8) contains supplementary material, which is available to authorized users.

Immunization in pregnancy safety surveillance in low and middle-income countries- field performance and validation of novel case definitions

BACKGROUND

A globally standardized approach in high and low and middle-income countries (LMIC) to actively monitor the safety of vaccines for pregnant women during development and implementation phases is critical. Brighton Collaboration's (BC) Global Alignment of Immunization Safety Assessment in Pregnancy (GAIA) project has developed globally standardized case definitions (CDs) of key obstetric and neonatal terms for the assessment of safety of vaccines in pregnancy. CDs are categorized into levels of diagnostic certainty, facilitating their use in varied settings. This study evaluates the field performance of CDs in LMIC.

METHODS

Data from pregnant participants of RCTs for trivalent inactivated influenza vaccine conducted at Chris Hani Baragwanath Academic Hospital, South Africa (SA) between 2011 and 2013 were reviewed retrospectively for preterm birth, stillbirth and hypertension CDs and the Gestational age assessment (GA) algorithm. Data from an ongoing pneumococcal vaccine trial (conducted at MRC Unit, The Gambia) were collected prospectively for GA.

RESULTS

For GA, 600 mother-infant dyads from Gambia and 155 mother-infant dyads from SA were reviewed. Level 2B (unsure LMP and US in 2nd trimester) was the most common level seen in Gambia (63%) and level 3B1 (unsure LMP with physical examination) in SA (43%). Preterm deliveries had similar results in SA. The pregnancy-induced hypertension definition performed well, with 96% (54/56) of cases fulfilling 'level 1' for 'preeclampsia with severe features'. 24 stillbirths were identified and 21 records were reviewed; 73.3% (11/15) of the stillbirths classified as antepartum by attending physicians and 83.3% (5/6) of the intrapartum stillbirths did not fulfil the criteria for any level of certainty.

CONCLUSION

BC CDs for neonatal and maternal outcomes (preterm and hypertension) and GA were sensitive, reliable and feasible to use in RCTs in SA and Gambia. Modifications to the stillbirth CD are required to improve its usefulness in varied settings.

Outcome assessment of emergency laparotomies and associated factors in low resource setting. A case series

BACKGROUND

Emergency laparotomy is a high risk procedure which is demonstrated by high morbidity and mortality. However, the problem is tremendous in resource limited settings and there is limited data on patient outcome. We aimed to assess postoperative patient outcome after emergency laparotomy and associated factors.

METHODS

An observational study was conducted in our hospital from March 11- June 30, 2015 using emergency laparotomy network tool. All consecutive surgical patients who underwent emergency laparotomy were included. Binary and multiple logistic regressions were employed using adjusted odds ratios and 95% CI, and P-value < 0.05 was considered to be statistically significant.

RESULT

A total of 260 patients were included in the study. The majority of patients had late presentation (>6hrs) to the hospital after the onset of symptoms of the diseases and surgical intervention after hospital admission. The incidences of postoperative morbidity and mortality were 39.2% and 3.5% respectively. Factors associated with postoperative morbidity were preoperative co-morbidity (AOR = 0.383, CI = 0.156-0.939) and bowel resection (AOR = 0.232, CI = 0.091-0.591). Factors associated with postoperative mortality were anesthetists' preoperative opinion on postoperative patient outcome (AOR = 0.067, CI = 0.008-0.564), level of consciousness during recovery from anaesthesia (AOR = 0.114, CI = 0.021-10.628) and any re-intervention within 30 days after primary operation (AOR = 0.083, CI = 0.009-0.750).

CONCLUSION AND RECOMMENDATION

The incidence of postoperative morbidity and mortality after emergency laparotomy were high. We recommend preoperative optimization, early surgical intervention, and involvement of senior professionals during operation in these risky surgical patients. Also, we recommend the use of WHO or equivalent Surgical Safety Checklist and establishment of perioperative patient care bundle including surgical ICU and radiology investigation modalities such as CT scan.

Epidemiology, clinical characteristics and outcomes of head injured patients in an Ethiopian emergency centre

INTRODUCTION

Head injury is a leading cause of mortality in Africa. We characterise the epidemiology and outcomes of head injury at an Ethiopian emergency centre.

METHODS

We conducted a prospective cohort study of all head injured patients presenting to the Emergency Centre of Tikur Anbessa Specialised Hospital, Addis Ababa. Data was collected via a standardised form from the patient's chart, radiology reports and operative reports. Patients were followed until discharge, facility transfer, death, or 7 days in hospital. Consent was obtained from the patient or substitute decision maker.

RESULTS

Among 204 head injured patients enrolled, the majority were <30 years old (51.0%) and male (86.8%). Forty-one percent of injuries occurred from road traffic accidents (RTAs). A significant number of patients had at least one indicator of severe injury on presentation: 51 (25.0%) had a GCS < 9, 53 (26.0%) had multi-system trauma, 95 (46.6%) had ≥1 abnormal vital sign and of the 133 patients with data available, 37 (27.8%) had a Revised Trauma Score (RTS) < 6. Patients injured by RTA were more likely to have indicators of severe injury than other mechanisms, including multi-system trauma (OR 3.2, 95% CI 1.7-6.2, p = 0.00), GCS < 9 (OR 3.7, 95% CI 1.8-7.4, p = 0.00), ≥1 abnormal vital sign (OR 2.5, 95% CI 1.4-4.6, p = 0.00) or an RTS score < 6 (OR 3.6, 95% CI 1.6-8.1, p = 0.00). Overall, 149 (73.0%) patients were discharged from hospital, 34 (16.7%) were transferred to another hospital, and 21 patients died (10.3%). In multivariable analysis, death was significantly associated with age over 60 years (aOR 68.8, 95% CI 2.0-2329.0, p = 0.02), GCS < 9 (aOR 14.8, 95% CI 2.2-99.5, p = 0.01), fixed bilateral pupils (aOR 39.1, 95% CI 4.2-362.8, p < 0.01) and hypoxia (oxygen saturation <90%; aOR 14.2%, 95% CI 2.6-123.9, p = 0.01).

CONCLUSION

Head injury represents a significant risk for morbidity and mortality in Ethiopia, of which RTA's increase injury severity. Targeted approaches to improving care of the injured may improve outcomes.

A novel tamponade agent for management of post partum hemorrhage: adaptation of the Xstat mini-sponge applicator for obstetric use

BACKGROUND

Although uterine tamponade is an effective treatment for postpartum hemorrhage (PPH), current methods have key limitations in their use, particularly in low resource settings. The XStat™ Mini Sponge Dressing (MSD) is approved for the management of non-compressible wounds in the battlefield/trauma setting. The MSD applies highly compressed medical sponges capable of stopping high-flow arterial bleeding within seconds. The objective of our study was to adopt the MSD for use in managing PPH.

METHODS

We performed desktop testing using a uterine model with pressure sensors to compare key design elements of the obstetrical prototype MSD (fundal pressure achieved, reduction in fluid loss, time to deploy, and time to remove) with alternativetechniques (uterine packing, balloon tamponade). To evaluate safety, we delivered the fetus of pregnant ewes by cesarean section and used the prototype to deliver the MSD into one uterine horn, and closed the hysterotomy. We followed the clinical recovery of animals (n = 3) over 24 h, and then removed the reproductive tract for histologic evaluation. To evaluate late effects, we surgically removed the MSDs after 24 h, and followed the clinical recovery of animals (n = 6) for an additional seven days before tissue removal.

RESULTS

The obstetrical prototype has a long tapered delivery system designed to be deployed during vaginal examination, and administers three times the volume of the approved MSD trauma bandage. The MSD are deployed within a mesh bag to facilitate removal by vaginaltraction. On desktop testing, the MSD resulted in the highest average fundal pressure (113 mmHg), followed by the MSD bag device (85.8 mmHg), gauze packing (15.5 mmHg), and the uterine balloon (8.2 mmHg). The MSD bag test group achieved the largest fluid flow reduction of -74%, followed by gauze packing (-55%), MSD (-35%), and uterine balloon (-19%). Animal testing demonstrated good uterine fill with no evidence of adverse clinical recovery, uterine trauma or infection at 24 h, or up to 7 days following device removal.

CONCLUSION

We adapted a highly effective trauma dressing and applicator for use in the treatment of severe PPH. Preliminary desktop and animal testing provide a basis for initial clinical trials in women.

A systematic review of screening instruments for depression for use in antenatal services in low resource settings

BACKGROUND

In low resource settings, short, valid and reliable instruments with good high sensitivity and specificity are essential for the screening of depression in antenatal care. A review of published evidence on screening instruments for depression for use in antenatal services in low resource settings was conducted. The aim of this review was to appraise the best available evidence on screening instruments suitable for detecting depression in antenatal care in low resource settings.

METHODS

Searching, selection, quality assessment, and data abstraction was done by two reviewers. ScienceDirect, CINAHL, MEDLINE, PubMed, SABINET and PsychARTICLES databases were searched using relevant search terms. Retrieved studies were evaluated for relevancy (whether psychometric data were reported) and quality. Data were synthesised and sensitivity and specificity of instruments were pooled using forest plots.

RESULTS

Eleven articles were included in the review. The methodological quality ranged from adequate to excellent. The review found 7 tools with varying levels of accuracy, sensitivity and specificity, including the Edinburgh Postnatal Depression Scale, Beck Depression Index, Centre for Epidemiologic Studies Depression Scale 20, Hamilton Rating Scale for Depression, Hopkins Symptoms Checklist-25, Kessler Psychological Distress Scale and Self-Reporting Questionnaire. The Edinburgh Postnatal Depression Scale was most common and had the highest level of accuracy (AUC = .965) and sensitivity.

CONCLUSION

This review suggests that the Edinburgh Postnatal Depression Scale can be a suitable instrument of preference for screening antenatal depression in low resource settings because of the reported level of accuracy, sensitivity and specificity.

PROSPERO REGISTRATION

CRD42015020316 .

Reduced neonatal mortality in a regional hospital in Mozambique linked to a Quality Improvement intervention

BACKGROUND

Neonatal mortality remains a serious health issue especially in low resource countries, where 99% of neonatal deaths occur. Doctors with Africa CUAMM is an Italian non-governmental organization in the field of healthcare that has been working in Africa since 1955. In Mozambique, at the Central Beira Hospital (CBH), it has a project with the aim of supporting the neonatal intensive care unit (NICU) and the Obstetrical Department of the CBH through a multi-level intervention. Our aim was to evaluate the effectiveness of CUAMM continuous Quality Improvement intervention in terms of reduction of the overall neonatal mortality rate in the NICU of CBH.

METHODS

A baseline analysis was performed in order to assess the actual standard of neonatal care. Subsequently, the intervention was focused on three main areas: infrastructure, equipment and clinical protocols improvement. A retrospective pre- (2013)/post- (2014) implementation analysis of clinical outcomes was performed.

RESULTS

Total population included 4,276 newborns, 2,118 (50%) born in 2013 and 2158 (50%) born after implementation. Baseline characteristics of the two groups were similar apart from a higher incidence of outborn neonates (33% vs 30%, p = 0.02) and a lower incidence of Apgar score < 7 at 5 min (37% vs 43%, p < 0.01). The rates of admissions for asphyxia (22% vs 30%), sepsis (4% vs 7%) and prematurity (18% vs 28%) increased between the two study period. Mortality rate for each of these causes decreased from before to after the implementation: asphyxia (34% vs 19%, p < 0.01), sepsis (39% vs 28%, p = 0.06) and prematurity (43% vs 33%, p < 0.01).

CONCLUSION

We found a reduction in mortality rate among newborns admitted to CBH's NICU after the first year of CUAMM intervention. Most of this reduction can be attributed to the decrease in deaths for asphyxia, sepsis and prematurity. A Quality Improvement intervention based on infrastructural, equipment and clinical objectives was associated with a reduction of neonatal mortality rate in a low-resource NICU.

A tool to improve competence in the management of emergency patients by rural clinic health workers: a pilot assessment on the Thai-Myanmar border

Background

Shoklo Malaria Research Unit has been providing health care in remote clinics on the Thai-Myanmar border to refugee and migrant populations since 1986 and 1995, respectively. Clinics are staffed by local health workers with a variety of training and experience. The need for a tool to improve the competence of local health workers in basic emergency assessment and management was recognised by medical faculty after observing the case mix seen at the clinic and reviewing the teaching programme that had been delivered in the past year (Jan-13 to March-14).

Aims

To pilot the development and evaluation of a simple teaching tool to improve competence in the assessment and management of acutely unwell patients by local health workers that can be delivered onsite with minimal resources.

Methods

A structured approach to common emergencies presenting to rural clinics and utilizing equipment available in the clinics was developed. A prospective repeated-measures observed structured clinical examination (OSCE) assessment design was used to score participants in their competence to assess and manage a scenario based ‘emergency patient’ at baseline, immediately post-course, and 8 weeks after the delivery of the teaching course. The assessment was conducted at 3 clinic sites and staff participation was voluntary. Participants filled out questionnaires on their confidence with different scenario based emergency patients.

Results

All staff who underwent the baseline assessment failed to carry out the essential steps in initial emergency assessment and management of an unconscious patient scenario. Following delivery of the teaching session, all groups showed improved competence in both objective assessment and subjective confidence levels.

Conclusions

Structured and practical teaching and learning with minimal theory in this resource limited setting had a positive short-term effect on the competence of individual staff to carry out an initial assessment and manage an acutely unwell patient. Health-worker confidence likewise improved. Workplace assessments are needed to determine if this type of skills training impacts upon mortality or near miss mortality patients at the clinic.

Electronic supplementary material

The online version of this article (doi:10.1186/s13031-015-0041-x) contains supplementary material, which is available to authorized users.

A feasible, acceptable and effective way to teach health care workers in low- and middle-income countries a method to manage acutely ill obstetric women

Maternal mortality is unacceptably high in Sub Saharan Africa, which accounts for 56% of all maternal deaths (WHO, 2012). Most maternal deaths are avoidable but with prompt recognition and timely intervention it is not inevitable that acute or critical maternal illness deteriorates to fatality (Firth and Ttendo, 2012). This paper discusses a project to provide multidisciplinary training in Maternal-Acute Illness Management (M-AIM) in a low resource setting in order to actively address the third delay to women accessing emergency obstetric care: prompt receipt of effective care on reaching a medical facility.

Adherence to antiepileptic drugs among children attending a tertiary health unit in a low resource setting

INTRODUCTION

Epilepsy is one of the neglected and highly stigmatised diseases, yet it is very common affecting about 70 million people worldwide. In Uganda, the estimated prevalence of epilepsy is 13% with about 156 new cases per 100,000 people per year. Adherence to antiepileptic drugs is crucial in achieving seizure control yet in Uganda; there is lack of information on adherence to antiepileptic drugs and the factors that affect this among children. This study was therefore designed to determine the level of adherence to antiepileptic drugs and the factors that are associated with non adherence.

METHODS

In a cross sectional study, 122 children who met the inclusion criteria were enrolled and interviewed using a pretested questionnaire. Assessment of adherence to antiepileptic drugs was done by self report and assay of serum drug levels of the antiepileptic drugs. Focus group discussions were held to further evaluate the factors that affect adherence.

RESULTS

Age range was 6 months - 16 years, male to female ratio 1.3:1 and majority had generalised seizures 76 (62.3%). Adherence to antiepileptic drugs by self report was 79.5% and 22.1% by drug levels. Majority of the children in both adherent and non adherent groups by self report had inadequate drug doses (95/122). Children were found to be more non-adherent if the caregiver had an occupation (p-value 0.030, 95%CI 1.18-28.78).

CONCLUSION

Majority of children had good adherence levels when estimated by self report. The caregiver having an occupation was found to increase the likelihood of non adherence in a child.

A multicentre study of advanced abdominal pregnancy: a review of six cases in low resource settings

Abdominal pregnancy has remained a big challenge worldwide especially in developing countries where there are limitations in diagnostic resources. The most important approach is to be vigilant for the unexpected as most patients present with no specific symptoms or clinical signs. It also poses great challenges in diagnosis and management, and is associated with a lot of morbidity and mortality. This series of six cases, each presenting in a peculiar way, typically illustrates these issues. The cases were managed in three different hospitals in the last 15 years. These series is aimed at highlighting the atypical presenting features of advanced abdominal pregnancy and the need for vigilance when there is suspicion of a case. It is also aimed at showing the difficulty of diagnosis and management of advanced abdominal pregnancy in low resource environment.