African Physicians Research Articles

Obesity Beliefs and Its Treatment: Insights from a Mixed Method Study in Overweight and Obese Patients and Health Care Personnel at Secondary Health Care Facility, Nigeria (OR08-04-19)

ObjectivesBackground: Overweight/obesity is a problem in Nigeria and roll out of treatment programmes at secondary health care level is a priority.Objective: This research aimed to compile a profile of behaviours and moderating factors for the development of a weight loss intervention. MethodsTwo groups of patients were recruited from outpatient clinics at secondary health care facilities. Group 1 (n = 328) completed a questionnaire on socio-demographics, medical history, body image, food choices and physical activity. Group 2 (n = 18) completed an in-depth interview on weight loss concepts/body image. Height and weight of both groups were measured. Six health care personnel were involved in key informant interviews. Quantitative data (QtD) were analysed with SPSS and in-depth interviews (qualitative = QID) with Nvivo. ResultsAbout 40% of survey respondents were overweight and 60% obese; 44.4% of in-depth interview respondents were overweight and 55.6% obese. Physical inactivity (55.8% inactive), low fruit/vegetable intake (consumed ≤ 2 times/day), high fat meat intake (consumed > 1 time/day) and large carbohydrate staple portions (consumed 2 times/day) were identified as key target behaviours (QtD). Moderating factors include underestimation of weight (QtD, QlD), satisfaction with current size although overweight/obese (QlD), co-morbidities and not obesity per se identified as problematic (QID), lack of insight in the role of physical inactivity (QlD), poor knowledge of healthy eating (QtD), too comfortable and relaxed, resulting in over-eating (QlD) and no control over body size (genes, God’s will) (QlD).From the health personnel perspective (three physicians, two matrons and one nutritionist) (QlD), only few recognised obesity as a disease. Obesity was not routinely screened for except it is obvious, partly due to lack of tools/skills. Lifestyle modification was mentioned as treatment but only the context of treatment of hypertension and type 2 diabetes mellitus. ConclusionsConsiderations for intervention development are poor food choices, physical inactivity, satisfaction with a large body size and not recognising obesity as such and lack of understanding of causes of obesity. Funding SourcesPostgraduate Academic Mobility for African Physician Scientists (PAMAPS), EU-PhD sponsorship.

Sydney Brenner: Nobel laureate and molecular biologist who specialised in comparative genomics

Andrew Cutraro/Redux Eyevine When 92 year old Nobel laureate Sydney Brenner died in Singapore in April, media outlets worldwide published the news. Brenner was honoured as a hero, a giant...

Evaluating a South African mobile application for healthcare professionals to improve diagnosis and notification of pesticide poisonings

BackgroundMobile health is a fast-developing field. The use of mobile health applications by healthcare professionals (HCPs) globally has increased considerably. While several studies in high income countries have investigated the use of mobile applications by HCPs in clinical practice, few have been conducted in low- and middle-income countries. The University of Cape Town developed a pesticide notification guideline which has been adapted and embedded into a South African Essential Medical Guidance mobile application. This study evaluated the usefulness of the guideline within a mobile application for improving the ability of HCPs to diagnose and notify on acute pesticide poisonings (APPs).MethodsA descriptive online questionnaire, with 15 open- and 20 closed-ended questions, was completed by 50 South African emergency medicine physicians and registrars (i.e. medical doctors training as specialists) between December 2015 to February 2016. Descriptive statistics were used to calculate response frequencies and percentages using SPSS version 23. Texts from the open-ended questions were thematically analysed. Fisher’s exact test was applied to determine associations.ResultsA significant association was found between participants’ knowledge that APP is a notifiable condition, and ever reporting the poisoning to the National Department of Health (p = 0.005). Thirty four percent of the participants were aware of the guideline within the Essential Medical Guidance application despite only seven participants having used it. Those who used the guideline found it provided useful information for the identification of unlabelled pesticides products and promoted reporting these cases to the National Department of Health for surveillance purposes. In addition, it appeared to facilitate the prompt diagnosis and treatment of APP cases, and most intended to continue using it for training and educational purposes.ConclusionsMobile health applications appear to support overburdened medical education programmes and promote better patient care. However, since most participants were not aware of the existence of the pesticide guideline within the studied essential medicine application, there is potential for the use of healthcare applications to play a more central role in healthcare systems and medical training. Furthermore, the field of medical informatics could support HCPs through mobile applications in improving reporting of APP.

South African physician emigration, return migration, and shared migration, 1991–2017: a registry-based analysis

Abstract Background Physician emigration—the so-called brain drain—is a topic of great concern to health workforce planners. South Africa has a high number of physician emigrants, yet there are few registry-based studies that have analysed whether these physicians remain abroad permanently. In this study, we aimed to use a registry-based approach to analyse return migration and shared migration in South African physicians. Methods We extracted information from registry records about South African trained physicians who had registered in Australia, Canada, New Zealand, the USA, or the UK (ACNUU nations) between 1991 and 2017. We used an attrition-based model to identify non-retiree dropouts from UK, New Zealand, and US registries and cross-referenced with a South African physician registry to determine return migration from these countries. Return migration counts in Canada were derived from secondary data from Canadian Medical Association surveys. Physicians who had active simultaneous registration in South Africa and one other nation were counted as shared migrants. Findings As of December, 2017, there were 11 224 South African trained physicians actively registered to practise in ACNUU nations, around a third (30·2%) fewer than the peak of 16 095 in 2003. Of these, 3596 (32·0%) held dual active registration (shared migration) in an ACNUU nation and South Africa. In 2017, 5008 physicians met criteria for return migration—that is, 30·1% of all non-retired South African physicians with a history of practising medicine in ACNUU countries. There has been a five-fold drop in emigration rates from South Africa between 1991 and 2017 (from 1·8% to 0·3% per year; UK −88·9%, non-UK −74·2%), negatively correlated with a substantial rise in GDP per capita growth within South Africa in time-adjusted models (–0·36% per $100 increase [p=0·01; 95% CI −0·089 to −0·632]). We noted a temporary increase in return migration between 1995 and 2009 and a simultaneous sustained increase in shared migration. Interpretation A registry-based approach allows simultaneous assessment of physician emigration, return migration, and shared migration. Our findings of decreasing rates of emigration and increasing return and shared migration rates suggest a mobility transition in medical migration in South Africa. Funding World Bank.

Missionary Photography: The Liberian Archive of Doctor Georgia Patton

This article focuses on the personal missionary experience of an African American woman physician, Dr Georgia Ester Lee Patton (1864–1900), later known as Georgia Washington. Patton worked in Liberia, a unique setting for missionary activities, being a colony established by former American slaves. The primary resource materials used here are missionary photographic archives, which comprise a distinct category of colonial cultural production. Photography assisted missions in promoting western achievements, disseminating Christianity, and advancing progress, by exposing Africans to western civilization. Such imagery was largely created by European photographers working within the social milieu of missionary organizations. Missionary photographs, therefore, functioned as an official public record of the missionary enterprise; today they are invaluable records of the histories of Christian missions around the globe. Missionary archives exist as both public and private archives. Private archives, as opposed to the images planned for a public audience, were compiled by individual missionaries and intended for private viewings. For this case study I use the private archive Patton compiled after she worked as a medical missionary in Liberia between 1893 and 1895. Patton later returned to Tennessee, where she became the first woman physician in the city of Memphis. This article seeks to determine how Patton’s perception of herself as an African American, as a woman, as a Christian, and as a physician influenced her unusual experience as a medical missionary in late nineteenth-century West Africa.

Teaching Medical Students in a New Rural Longitudinal Clerkship: Opportunities and Constraints.

Background:Medical schools in Africa are responding to the call to increase numbers of medical graduates by up-scaling decentralized clinical training. One approach to decentralized clinical training is the longitudinal integrated clerkship (LIC), where students benefit from continuity of setting and supervision. The ability of family physician supervisors to take responsibility for the clinical training of medical students over a longer period than the usual, in addition to managing their extensive role on the district health platform, is central to the success of such training.Objective:This study investigated the teaching experiences of family physicians as clinical supervisors in a newly introduced LIC model in a rural sub-district in the Western Cape, South Africa.Method:Nine semi-structured interviews were conducted with six family physicians as part of the Stellenbosch University Rural Medical Education Partnership Initiative (SURMEPI) five-year longitudinal study. Code lists were developed inductively using Atlas.ti v7, they were compared, integrated, and categories were identified. Emerging common themes were developed.Findings:Three overarching themes emerged from the data, each containing subthemes. The rural platform was seen to be an enabling learning space for the LIC students. The family physicians’ experienced their new teaching role in the LIC as empowering, but also challenging. Lack of time for teaching and the unstructured nature of the work emerged as constraints. Despite being uncertain about the new LIC model, the family physicians felt that it was easier to manage than anticipated.Conclusion:The centrality of the rural context framed the teaching experiences of the family physicians in the new LIC, forming the pivot around which constraints and opportunities for teaching arose. The African family physician is well positioned to make an important contribution to the upscaling of decentralized medical training, but would need to be supported by academic institutions and health service managers in their teaching role.

Barriers to the availability and accessibility of controlled medicines for chronic pain in Africa.

Africans endure a high burden of pain and suffering from HIV/AIDS and cancer, yet receive a meager amount of the world's pain medication. This tragedy occurs needlessly, given that inexpensive, effective and easily administered interventions are available. WHO has a 'three-step analgesic ladder' framework for managing cancer pain. This widely adopted clinical practice guideline is an integral part of palliative care programs and has also been applied to non-cancer pain. However, untreated pain is a major public health problem due to the discordance between scientific evidence and public policy. Historically, the International Narcotics Board has taken an unbalanced prohibitionist approach to international drug control that has emphasized suppressing controlled substances over making them available for medical and scientific purposes. The procurement process for controlled pain medications in most African countries is a morass of restrictions that make it exceedingly difficult for patients to obtain these drugs. Often, these restrictions arise in part from a misunderstanding of addiction and dependence on opiates. The result has been widespread 'opiophobia' among African policy makers and physicians. A host of factors have misaligned the analgesic pharmaceutical supply chain. Taken together, access to medically necessary controlled substance in sub-Saharan Africa is suboptimal.

Introduction of the Teaching of Traditional Medicine in Medical Schools in Togo

Objectives: The use of traditional medicine is widespread in many countries of the world. A study found that 80% of rural populations living in developing countries depend on traditional medicine for their health needs. African Traditional Medicine remains poorly documented. However, because of this large attendance by the population, African physicians cannot continue to ignore this fact. The purpose of this study was to conduct a survey among physicians to find out what they think about the introduction of the teaching of ATM in medical schools in Togo. Methods: This is a cross-sectional survey of Togolese physicians over a period of a year, from December 1st, 2016 to November 30th, 2017. An anonymous questionnaire was sent to them and retrieved after filling. The socio-demographic and the general data on traditional medicine were asked. Results: 276 physicians completed the questionnaire. Their average age was 34.41 years. These physicians exercised mainly in public hospitals (91.3%). General practitioners were predominant (67.4%). The majority (62.7%) of the physicians surveyed believed in the existence of the ATM and 57.6% had at least once witnessed its success. ATM teaching in medical schools was approved by 209 (75.7%) of the physicians surveyed. Conclusion: The teaching of African traditional medicine in medical schools is widely accepted by the physicians surveyed. The challenges of this teaching are important because of the lack of documentation and resource persons.

An Anecdotal Experience of Low Back Pain – What Can We Do Differently?

Low back pain is a very common disease that can be very painful and debilitating. It is also a costly disease which accounts for billions of dollars lost to health care and absence from work. Low back pain is more disabling in developing countries because lack of resources makes proper health care inaccessible to many people. In developing countries many people are employed in manual work and low back pain takes them away from a source of income. Most manual workers in these settings do not have insurance policies to support them when they are absent from work due to disease. Pharmacological treatment of low back pain has sometimes resulted in opioid dependence which has reached epidemic proportions in some western countries. Opioid dependence is costly to treat and leads to deterioration or loss of human life. It would therefore be beneficial to find an inexpensive and effective treatment of low back pain which has no dependency hazard. We describe the experiences of an African family physician who suffered from low back pain from early adulthood. He found that drinking lots of water alleviated his low back pain. He found that his low back pain patients also benefited from drinking lots of water when they had an episode of low back pain. We intend to do quantitative studies to test the effectiveness of water treatment in low back pain.

Motivations of South African physicians specialising in public health

ABSTRACTBackground: South African physicians can specialise in public health through a four-year ‘registrar’ programme. Despite national health policies that seemingly value public health (PH) approaches, the Public Health Medicine (PHM) speciality is largely invisible in the health services. Nevertheless, many physicians enrol for specialist training.Objectives: This study investigated physicians’ motivations for specialising in PHM, their intended career paths, perceptions of training, and perspectives about the future of the speciality.Methods: Focus groups and in-depth interviews were conducted with specialists-in-training and newly qualified specialists, and thematic analysis of transcripts was performed.Results: Motivations, often driven by difficult experiences as young physicians in poorly resourced clinical settings, stemmed from a commitment to improving communities’ health and desire to impact on perceived failing health systems. Rather than ‘exiting’ the South African health service, selecting PHM specialist training enacted participants’ ‘loyalty’ to population health. Participants anticipated carving out their own careers due to an absence of public sector career paths. They believed specialists’ contribution centred on providing ‘public health intelligence’ – finding and interpreting information; supporting services through management and leadership; and inputting into policymaking and planning.Conclusions: Competencies of PHM specialists should be refined to inform and improve management of this scarce human resource for health. This is particularly important given the proposed major health reforms towards universal health coverage in South Africa presently. In addition, findings highlight the importance of physicians’ early work experiences where avenues for expressing ‘voice’, mediated by ‘loyalty’, could be utilised to improve public sector health systems.

Family medicine in a globally-connected world: a South African perspective and the RCGP International and Overseas Network.

The recent launch of the International and Overseas Network (ION) by the Royal College of General Practitioners (RCGP), presented a unique opportunity to review family medicine across the globe. This article looks at the future of family medicine from a South African perspective. In 2007, family physicians were recognised for the first time as medical specialists in South Africa. Training is exclusively in the state sector, and predominantly hospital-based. Family physicians lead ward-based outreach teams composed mostly of community health workers and primary healthcare nurses.1 Unlike many British GPs, most South African family physicians also have other, more traditional hospital roles such as casualty, anaesthesia, or surgery duties. In 2014, to overcome the challenge of training to established international standards while retaining sensitivity to local …

Africa and health: a Commission to accelerate success

The final results of a 4-year project to analyse the challenges and opportunities for health in sub-Saharan Africa are now published as a Lancet Commission—The Path to Longer and Healthier Lives for All Africans by 2030—led by African physicians, health scientists, and policy makers. 1 Agyepong IA Sewankambo N Binagwaho A et al. The path to longer and healthier lives for all Africans by 2030: the Lancet Commission on the future of health in sub-Saharan Africa. Lancet. 2017; (published online Sept 13.)http://dx.doi.org/10.1016/S0140-6736(17)31509-X Summary Full Text Full Text PDF PubMed Scopus (113) Google Scholar Their conclusion is one of qualified optimism, grounded in a rigorous appraisal of new evidence and past experience. The vision of the Commission is that Africans should expect the same opportunities for health by 2030 as all other peoples. But that hopeful message is based on a further proposition—that more of the same, in terms of policies and programmes, is not enough. The path to longer and healthier lives for all Africans by 2030: the Lancet Commission on the future of health in sub-Saharan AfricaSub-Saharan Africa's health challenges are numerous and wide-ranging. Most sub-Saharan countries face a double burden of traditional, persisting health challenges, such as infectious diseases, malnutrition, and child and maternal mortality, and emerging challenges from an increasing prevalence of chronic conditions, mental health disorders, injuries, and health problems related to climate change and environmental degradation. Although there has been real progress on many health indicators, life expectancy and most population health indicators remain behind most low-income and middle-income countries in other parts of the world. Full-Text PDF

A comparison of physician emigration from Africa to the United States of America between 2005 and 2015

BackgroundMigration of health professionals has been a cause for global concern, in particular migration from African countries with a high disease burden and already fragile health systems. An estimated one fifth of African-born physicians are working in high-income countries. Lack of good data makes it difficult to determine what constitutes “African” physicians, as most studies do not distinguish between their country of citizenship and country of training. Thus, the real extent of migration from African countries to the United States (US) remains unclear. This paper quantifies where African migrant physicians come from, where they were educated, and how these trends have changed over time.MethodsWe combined data from the Educational Commission for Foreign Medical Graduates with the 2005 and 2015 American Medical Association Physician Masterfiles. Using a repeated cross-sectional study design, we reviewed the available data, including medical school attended, country of medical school, and citizenship when entering medical school.ResultsThe outflow of African-educated physicians to the US has increased over the past 10 years, from 10 684 in 2005 to 13 584 in 2015 (27.1% increase). This represents 5.9% of all international medical graduates in the US workforce in 2015. The number of African-educated physicians who graduated from medical schools in sub-Saharan countries was 2014 in 2005 and 8150 in 2015 (304.6% increase). We found four distinct categorizations of African-trained physicians migrating to the US: (1) citizens from an African country who attended medical school in their own country (86.2%, n = 11,697); (2) citizens from an African country who attended medical school in another African country (2.3%, n = 317); (3) US citizens who attended medical school in an African country (4.0%, n = 537); (4) citizens from a country outside Africa, and other than the United States, who attended medical school in an African country (7.5%, n = 1013). Overall, six schools in Africa provided half of all African-educated physicians.ConclusionsThe number of African-educated physicians in the US has increased over the past 10 years. We have distinguished four migration patterns, based on citizenship and country of medical school. The majority of African graduates come to the US from relatively few countries, and from a limited number of medical schools. A proportion are not citizens of the country where they attended medical school, highlighting the internationalization of medical education.

Breaking Bad News to Togolese Patients

ABSTRACTThe aim of this study was to map Togolese people’s positions regarding the breaking of bad news to elderly patients. Two hundred eleven participants who had in the past received bad medical news were presented with 72 vignettes depicting communication of bad news to elderly female patients and asked to indicate the acceptability of the physician’s conduct in each case. The vignettes were all combinations of five factors: (a) the severity of the disease, (b) the patient’s wishes about disclosure, (c) the level of social support during hospitalization, (d) the patient’s psychological robustness, and (e) the physician’s decision about how to communicate the bad news. Five qualitatively different positions were found. Two percent of the participants preferred that the physician always tell the full truth to both the patient and her relatives, 8% preferred that the truth be told depending on the physician’s perception of the situation, 15% preferred that the physician tell the truth but understood that in some cases nondisclosure to the patient was not inappropriate, 33% preferred that the physician tell the full truth to the relatives but not as much information to the patient, and 42% preferred that the physician tell the full truth to the relatives only. These findings present a challenge to European physicians taking care of African patients living in Europe or working in African hospitals, and to African physicians trained in Europe and now working in their home countries. If these physicians respect the imperative of always telling the truth directly to their patients, their behavior may trigger anger and considerable misunderstanding among African patients and their families.

South Africa has joined a global initiative for Family Medicine advocacy

The international #1WordforFamilyMedicine initiative serves to explore the identity of family physicians and allows the international Family Medicine community to collaborate on advocating the discipline. South African family physicians provided 42 responses via a social media and online survey. Two “word cloud” images were created based on two icons recognised as being truly South African around the world – the national flag and former president Nelson Mandela. The #1WorldforFamilyMedicine initiative was promoted by the World Organization of Family Doctors across the globe to help celebrate World Family Doctor Day on 19 May 2015. To date, over 70 images have been created in 50 different countries on six continents. The images represent family physicians’ love for their profession and the community they serve. It is hoped that this initiative will help to inspire current and future Family Medicine and primary care providers.

When Patients Leave.

I thought the visit went well. I walked in with a warm hello, shook hands, introduced myself, sat down, and began to listen. No computer screen was open, no interruptions occurred, and I was present. I heard the story, performed an examination, and then we discussed the diagnosis, prognosis, and treatment options. The patient and her daughters had many questions, and I tried to address them all. We warmly smiled at each other, set up a plan for new imaging, and scheduled a visit thereafter to finalize our next course of action. Except a week later I noticed my patient was no longer on my schedule and the nurse told me that she called to cancel her follow-up appointment. She was going elsewhere. No need to call back. Fresh out of a fellowship that routinely saw patients for clinical trials and second opinions, a patient leaving after my first opinion felt like a personal failure. Why would she not stay? Was I too pessimistic, too optimistic, too confusing, or not confident enough? Did I seem too young or too new? I spent days ruminating in my spare time, wishing it were appropriate to call her and ask why she chose to never return. While having a conversation with her referring urologist about a different patient, the topic was not broached by either one of us. With no clear resolution available, I tried to push the unsettling feeling away. At the time, I did not appreciate that the experience would not be unique, that many patients who would choose to leave my care would do so without my fully understanding why, and that learning from those experiences is challenging. Patients who leave fall into two general categories: the more frequent cases of those who come once and never return, and the more rare, but also more painful, instances of those who switch physicians after a relationship has been established. Sometimes it is easy to accept these events—coming for a confirmatory second opinion, moving care closer to home, or seeking a clinical trial elsewhere are practical and understandable. In oncology, delivering bad news or broaching the notion of hospice may sometimes trigger anger, resentment, and a belief that the doctor is giving up, leaving little doubt as to the cause behind a patient switching care. Often though, the reason a patient does not return is murky, personal, and difficult to discern. A 1930 address by a South African physician reminded the younger doctors that “when they grew older they too would puzzle why patients left them for some inexplicable reason...but examining the various reasons and considering the inevitability of the course of events may make us more content andmore sociable members of both our profession and the community at large.” Mymore seasoned colleagues echo this sentiment, saying that it gets easier, that one simply accepts the fact that some patients will leave, that not all relationships work out. Yet, even they seem dejected, frustrated, and puzzled when speaking about patients who have left their care. A 1963 study from the United Kingdom examined the psychologic consequences to primary care physicians when patients left them. The authors found that “doctors were quite disproportionately upset when their patients left them, not because their livelihood seemed endangered, but because it constituted a threat to their self-esteem.” A patient leaving led to “vague uneasiness to deep disquiet.” Confronting the loss of a patient not due to illness but to choice, to feel suddenly interchangeable and distrusted, is difficult and uncomfortable. There are few data on the rate or motives behind patients leaving a doctor. A 1957 paper discussed 13 reasons patients may change physicians, emphasizing a failure to inspire confidence, establish rapport, and demonstrate friendship for the patient. A more recent qualitative analysis of patients’ online comments about their physicians suggested that a multitude of factors—including the interpersonalmanner and technical competence of a doctor, but also system issues that are outside the direct patient-physician interaction—are important in forming a patient’s opinion of a physician. The attributes that are desired in a physician were characterized in a survey of 192 patients seen by various specialists in the Mayo Clinic system. The patients described an ideal physician as someone who is confident, empathetic, humane, personal, forthright, respectful, and thorough. Although some physicians are

Truncating a disease. The reduction of silica hazards to silicosis at the 1930 international labor office conference on silicosis in Johannesburg.

The current nosology and etiology of silicosis were officially adopted by the 1930 International Labor Office (ILO) Conference on silicosis in Johannesburg. Convened by the International Labor Office and by the Transvaal Chamber of Mines, it paved the way to the adoption of a 1934 ILO convention which recognized silicosis as an occupational disease. Even though it constituted a social and sanitary turning point, the Johannesburg conference, strongly influenced by South African physicians working for the gold mining industry, reduced silica hazards to silicosis, an equation which is questioned nowadays. While the definition of silicosis adopted in 1930 was a major step in the recognition of occupational pneumoconioses, it also led to the under-identification of some pathogenic effects of silica. Going back to history opens new avenues for contemporary medical research.

Large Scale Genetic Research on Neuropsychiatric Disorders in African Populations is Needed

Large Scale Genetic Research on Neuropsychiatric Disorders in African Populations is Needed

African Female Physicians and Nurses in the Global Care Chain: Qualitative Explorations from Five Destination Countries

Migration of health professionals is an important policy issue for both source and destination countries around the world. The majority of migrant care workers in industrialized countries today are women. However, the dimension of mobility of highly skilled females from countries of the global south has been almost entirely neglected for many years. This paper explores the experiences of high-skilled female African migrant health-workers (MHW) utilising the framework of Global Care Chain (GCC) research. In the frame of the EU-project HURAPRIM (Human Resources for Primary Health Care in Africa), the research team conducted 88 semi-structured interviews with female and male African MHWs in five countries (Botswana, South Africa, Belgium, Austria, UK) from July 2011 until April 2012. For this paper we analysed the 34 interviews with female physicians and nurses using the qualitative framework analysis approach and the software atlas.ti. In terms of the effect of the migration on their career, almost all of the respondents experienced short-term, long-term or permanent inability to work as health-care professionals; few however also reported a positive career development post-migration. Discrimination based on a foreign nationality, race or gender was reported by many of our respondents, physicians and nurses alike, whether they worked in an African or a European country. Our study shows that in addition to the phenomenon of deskilling often reported in GCC research, many female MHW are unable to work according to their qualifications due to the fact that their diplomas are not recognized in the country of destination. Policy strategies are needed regarding integration of migrants in the labour market and working against discrimination based on race and gender.

Retention of Skills 2 Years After Postpartum Hemorrhage Simulation Training in Rural Rwanda [137

INTRODUCTION: Obstetric hemorrhage is the leading cause of maternal mortality in Rwanda. Retention of skills was assessed 2 years after a postpartum hemorrhage simulation training at a rural Rwandan hospital. METHODS: In 2012, two African generalist physicians working in a rural Rwandan hospital conducted simulation-based training in postpartum hemorrhage management for their colleagues. These 11 physicians were approached again in 2014 and asked to participate in the current study. Retention simulation drills were conducted using the same simulation scenario as in the initial training. Median scores and interquartile ranges were calculated. The Wilcoxon signed-rank-sum test was used to compare preintervention and postintervention scores and retention scores in three performance areas: communication, evaluation, and management. RESULTS: Six of the original 11 participants were available and consented to participate. Comparisons of the preintervention and 2-year retention scores in each of three performance areas revealed retention-of-skill scores that were not significantly different than the postintervention scores after the original simulation training: median (interquartile range) preintervention compared with retention communication: 0.5 (0, 2) compared with 3.5 (2, 4) (P=.03) and postintervention compared with retention communication: 3.5 (3, 4) compared with 3.5 (2, 4) (P=1.0); preintervention compared with retention evaluation: 2 (2, 4) compared with 5 (4, 5) (P=.03) and postintervention compared with retention evaluation: 4.5 (2, 5) compared with 5 (4, 5) (P=.16); and preintervention compared with retention management: 2.5 (2, 5) compared with 7 (7, 10) (P=.09) and postintervention compared with retention management: 10 (7, 12) compared with 7 (7, 10) (P=.46). CONCLUSION: Simulation-based training may be an effective method for teaching communication, evaluation, and management skills for postpartum hemorrhage in rural Africa.