Local Health Care Providers Research Articles

166 Attitudes, Practices, and Barriers to Sexual Health Assessments of Patients Amongst Practicing Oncologists: Survey Data from a Group of Local Oncology Healthcare Providers

Despite the endorsement by national survivorship guidelines, sexual health is infrequently discussed among cancer providers and cancer survivors.1,2 Previous studies evaluating this subject are limited and lack consistency in the attitudes and practice patterns among Oncologists and advanced practice providers (APPs) toward discussing sexuality with their patients.3 The goal of our study was to assess how often practicing oncologists, their nurse practitioners, and their physician assistants are discussing sexual health issues with their cancer patients. We also evaluated how comfortable providers are discussing sexual health, whether they have received formal didactic training in various sexual health issues, and the barriers that they believe prevent them from discussing their sexual health with their patients. We distributed the 18-item, validated Sexual Health Attitudes Questionnaire to 88 practicing Oncologists and Oncology APPs in our geographic region by email. The instrument evaluates: attitudes towards sexuality, education, and barriers to discussion of sexual health with Oncology patients. Stata IC was used for statistical analysis.

Analysis of the Implementation, User Perspectives, and Feedback From a Mobile Health Intervention for Individuals Living With Hypertension (DREAM-GLOBAL): Mixed Methods Study.

BackgroundDREAM-GLOBAL (Diagnosing hypertension—Engaging Action and Management in Getting Lower Blood Pressure in Indigenous and low- and middle-income countries) studied a SMS text messaging–based system for blood pressure measurement and hypertension management in Canadian Aboriginal and Tanzanian communities. The use of SMS text messages is an emerging point of interest in global health care initiatives because of their scalability, customizability, transferability, and cost-effectiveness.ObjectiveThe study aim was to assess the effect on the difference in blood pressure reduction of active hypertension management messages or passive health behavior messages. The system was designed to be implemented in remote areas with wireless availability. This study described the implementation and evaluation of technical components, including quantitative data from the transmission of blood pressure measurements and qualitative data collected on the operational aspects of the system from participants, health care providers, and community leadership.MethodsThe study was implemented in six remote Indigenous Canadian and two rural Tanzanian communities. Blood pressure readings were taken by a community health worker and transmitted to a mobile phone via Bluetooth, then by wireless to a programmed central server. From the server, the readings were sent to the participant’s own phone as well. Participants also received biweekly tailored SMS text messages on their phones. Quantitative data on blood pressure reading transmissions were collected from the study central server. Qualitative data were collected by surveys, focus groups, and key informant interviews of participants, health care providers, and health leadership.ResultsIn Canada, between February 2014 and February 2017, 2818 blood pressure readings from 243 patients were transmitted to the central server. In Tanzania, between October 2014 and August 2015, 1165 readings from 130 patients were transmitted to the central server. The use of Bluetooth technology enabled the secure, reliable transmission of information from participants to their health care provider. The timing and frequency were satisfactory to 137 of 187 (73.2%) of participants, supporting the process of sending weekly messages twice on Mondays and Thursdays at 11 am. A total of 97.0% (164/169) of the participants surveyed said they would recommend participation in the DREAM-GLOBAL program to a friend or relative with hypertension.ConclusionsIn remote communities, the DREAM-GLOBAL study helped local health care providers deliver a blood pressure management program that enabled patients and community workers to feel connected. The technical components of the study were implemented as planned, and patients felt supported in their management through the SMS text messaging and mobile health program. Technological issues were solved with troubleshooting. Overall, the technical aspects of this research program enhanced clinical care and study evaluation and were well received by participants, health care workers, and community leadership.Trial RegistrationClinicaltrials.gov NCT02111226; https://clinicaltrials.gov/ct2/show/NCT02111226.

An Innovative Telemedicine Platform to Provide Expert Access to Patients with Chronic Lymphocytic Leukemia (CLL)

An Innovative Telemedicine Platform to Provide Expert Access to Patients with Chronic Lymphocytic Leukemia (CLL)

BUILDING DEMENTIA-FRIENDLY COMMUNITY IN MICHIGAN: THE EXPERIENCES OF BATTLE CREEK

Alzheimer’s disease is now the 6th leading cause of death in Calhoun County – a mostly rural county of 156,000 people in southwest Michigan. In 2017, a cross-sector collaborative launched Dementia Friendly Battle Creek led by CareWell Services Area Agency on Aging. This study focuses on evaluation of the progress and outcomes of this initiative. The goal is to create a community that features high awareness of dementia, coordinated systems of care, and an environment that promotes dignity and engagement of PWD. Using participatory community planning, three Pillars of Impact were developed: Awareness, Coordination, and Environment. More than 500 people have engaged in the effort through trainings, educational programs, expanded supportive services, and the creation of integrated pathways of care for PWD. Additionally, more than $100,000 has been leveraged to support the effort. Challenges included sustaining momentum & gaining buy-in from local municipalities and health care providers.

Risk Stratification of Fetal Cardiac Anomalies in an Underserved Population Using Telecardiology

To evaluate a fetal telecardiology program in a medically underserved area. We conducted a prospective case series of pregnant women at 18-38 weeks of gestation with risk factors for fetal congenital heart disease. Obstetric ultrasonographers performed fetal echocardiograms (local site) that were read in real time. The results were given to the mother by a fetal cardiologist at a children's hospital 243 miles and two mountain passes away (distant site). We evaluated the fetal telecardiology program in five domains: 1) education of obstetric ultrasonographers before initiation of telecardiology services, 2) process and efficiency, 3) patient satisfaction, 4) economic effects, and 5) accuracy of cardiac diagnosis and success of risk stratification. The program was initiated on November 12, 2015, and here we describe its first 37 months. Over the initial training period of 3 months and about 70 examinations, obstetric ultrasonographers improved their identification of fetal congenital heart disease. Telecardiology was performed once a week and also for suspected fetal congenital heart disease or arrhythmia outside clinic hours, for a total of 455 examinations. All mothers preferred having their fetal cardiac evaluations performed locally as opposed to traveling to the distant center. The estimated cost to parents for fetal cardiac evaluation at the distant center was nine times greater than that of telecardiology ($581 vs $61). Congenital heart disease or arrhythmia was diagnosed in 28 and 15 fetuses, respectively; there was one false-negative result. All fetuses were correctly risk-stratified with respect to delivery location. Neither diagnostic quality nor patient satisfaction were sacrificed with telecardiology. The program was feasible, empowered the local health care providers and ultrasonographers, offered strong economic advantages to families, and offered the benefit of timely standard-of-care, face-to-face consultation without travel. Based on the success of this program, further studies are warranted to assess its replicability.

Inequities in the global representation of sites participating in large, multicentre dialysis trials: a systematic review

BackgroundThe number of dialysis recipients is growing worldwide, making it important that the full range of patient populations are represented in randomised trials. As trial recruitment has not previously been...

1682. Dengue Fever Outbreak Investigation in Upper Egypt in 2015

BackgroundSurveillance is the backbone of infectious diseases control but an outbreak of a new pathogen to a developing country may have devastating consequences given less prepared healthcare systems in such countries. In October 2015, there was a sharp rise of febrile illnesses reported in Dairot Fever Hospital which prompted the general department for fever hospitals in the Egyptian ministry of health (MOH) to constitute a scientific committee for field visit study in Dairot fever hospital.MethodsThe committee held meetings at Dairot fever hospital, educated local healthcare providers, examined all isolated patients and requested samples of 118 isolated patients to be sent to central laboratories of MOH. Entomological services were also part of the committee and surveillance was started in the affected area.ResultsOut of 118 samples, 28 came back positive for Dengue virus type 1 by ELISA and PCR. Entomological surveillance revealed the presence of Aedes aegypti larvae and adult mosquito at the sites where cases were living; consequently, entomological control measures for dengue vector were immediately set leading to a dramatic decline in the density of adult mosquito (from 23% to 0%) and larvae (from 25% to 0.5%).ConclusionThe prompt response of the MOH in Egypt led to rapid control of Dengue fever outbreak but educating healthcare workers about possible imported infectious diseases would have halted the outbreak much earlier which shows the importance of Infectious Diseases training in developing countries.Disclosures All authors: No reported disclosures.

Development and Implementation of a Culturally Appropriate Education Program to Increase Cervical Cancer Screening among Maasai Women in Rural Tanzania.

Background:In Tanzania, the incidence of cervical cancer is nearly ten times that found in the US. Tanzanian women of the traditional Maasai tribe are financially and educationally marginalized and face a language barrier that reduces access to health care. While cervical cancer (CACX) screening programs are available locally, in our experience, Maasai women were less likely to use these services compared to local women of other tribal backgrounds.Objectives:A novel patient education program was designed to teach Maasai women about the natural history of cervical cancer and available screening and treatment. The program addressed the importance of preventative health and informed consent. Additionally, we sought to better understand the specific barriers Maasai women face in accessing and utilizing CACX screening services.Methods:The program used simple, scripted language translated into Maa language, the Maasai native language, with accompanying culturally appropriate 3D models. The effectiveness of the program was evaluated through pre and post-intervention surveys administered to Maasai and non-Maasai women as well as local healthcare providers, assessing knowledge of cervical cancer, screening, and treatment. Paired t-test analyses were used to analyze significance. Extensive question and answer sessions followed the education sessions from which additional barriers to screening were identified.Findings:Maasai women had minimal understanding of preventative health services prior to the intervention. While all groups showed an increase in knowledge following the education program, Maasai women demonstrated the greatest statistically significant improvement in knowledge. The proportion of Maasai women in attendance to CACX screening clinics increased by 18% after the intervention.Conclusions:Through a culturally sensitive and accessible patient education program, Maasai women gained knowledge of cervical cancer screening and treatment. This program serves as an adaptable model for other marginalized populations to increase patient understanding and informed consent, and to address issues that pertain to underutilization of health care services.

1107Reduction of cardiovascular disease risk factors in rural, medically under-served, socioeconomically distressed, high-risk individuals: a randomized controlled trial

Abstract Background People in rural, socioeconomically distressed areas of the world suffer from marked cardiovascular disease (CVD) disparities. Despite the CVD disparities seen in rural, distressed areas, efforts directed toward CVD risk reduction and prevention are limited. We conducted a randomized, controlled trial to determine the effect of an individualized, culturally appropriate, self-care CVD risk reduction intervention (HeartHealth) compared to referral of patients to a primary care provider for usual care on the following CVD risk factors: tobacco use, blood pressure, lipid profile, body mass index, depressive symptoms, and physical activity levels. Methods The study protocol and intervention were developed with a community advisory board of lay community members, business owners, local government officials, church leaders, and healthcare providers. We enrolled 355 individuals living in Appalachia with two or more CVD risk factors. The intervention was delivered in person to groups of 10 or fewer individuals over 12 weeks. In the first session, participants chose their CVD risk reduction goals. HeartHealth was designed to provide participants with self-care skills targeting CVD risk reduction while reducing barriers to risk reduction found in austere rural environments. The targeted CVD risk factors were measured at baseline and 4 and 12 months post-intervention. Repeated measures data were analyzed with mixed models. Results More individuals in the intervention group compared to the control group met their lifestyle change goal (50% vs 16%, p<0.001). The intervention produced a positive impact on systolic blood pressure (p=0.002, time X group effect), diastolic blood pressure (p=0.001, time x group), total cholesterol (p=0.026, time x group), high density lipoprotein (p=0.002, time x group), body mass index (p=0.017, time x group), smoking status (p=0.01), depressive symptoms (p=0.01, time x group), and steps per day (p=0.001, time x group). Compared to the control group, improvement was seen at 4 months in these risk factors and the positive changes were maintained through 12 months. There were no differences seen across time by group in low density lipoprotein or triglyceride levels. Conclusion Interventions like HeartHealth that focus on self-care and that are derived in collaboration with the community of interest are effective in medically underserved, socioeconomically distressed rural areas. Acknowledgement/Funding Patient Centered Outcomes Research Institute

Bottom-up development of national obstetric guidelines in middle-income country Suriname

BackgroundObstetric guidelines are useful to improve the quality of care. Availability of international guidelines has rapidly increased, however the contextualization to enhance feasibility of implementation in health facilities in low and middle-income settings has only been described in literature in a few instances. This study describes the approach and lessons learned from the ‘bottom-up’ development process of context-tailored national obstetric guidelines in middle-income country Suriname.MethodsLocal obstetric health care providers initiated the guideline development process in Suriname in August 2016 for two common obstetric conditions: hypertensive disorders of pregnancy (HDP) and post partum haemorrhage (PPH).ResultsThe process consisted of six steps: (1) determination of how and why women died, (2) interviews and observations of local clinical practice, (3) review of international guidelines, (4) development of a primary set of guidelines, (5) initiation of a national discussion on the guidelines content and (6) establishment of the final guidelines based on consensus. Maternal enquiry of HDP- and PPH-related maternal deaths revealed substandard care in 90 and 95% of cases, respectively. An assessment of the management through interviews and labour observations identified gaps in quality of the provided care and large discrepancies in the management of HDP and PPH between the hospitals. International recommendations were considered unfeasible and were inconsistent when compared to each other. Local health care providers and stakeholders convened to create national context-tailored guidelines based on adapted international recommendations. The guidelines were developed within four months and locally implemented.ConclusionDevelopment of national context-tailored guidelines is achievable in a middle-income country when using a ‘bottom-up’ approach that involves all obstetric health care providers and stakeholders in the earliest phase. We hope the descriptive process of guideline development is helpful for other countries in need of nationwide guidelines.

Family Medicine Rural Training Track Residencies: Risks and Resilience.

Family medicine rural training track (RTT) residency programs produce a higher proportion of graduates who choose rural practice than other programs, yet RTTs face continuing threats to their existence. This study sought to understand threats to RTT sustainability and resilience factors that enable RTTs to thrive. In 2014 and 2015, the authors conducted semistructured interviews of 21 RTT leaders representing two closed programs and 22 functioning programs. Interview topics included program strengths providing resilience and sustainability, risk factors for closure or vulnerabilities threatening sustainability, and advice for other RTTs. The authors performed a content analysis, coding pertinent themes in all interview data. From the top three assets, risks, and advice that respondents offered, the following nine themes emerged, in order from most to least mentioned: leadership, faculty and teaching resources, program support, finances, resident recruitment, program attributes, program mission, political and environmental context, and patient-related clinical experiences. Interviewees frequently reported multifactorial causes for RTT sustainability or closure. Numerous factors identified, such as distance, can operate as positive or negative influences for program resilience, depending on place and context. Resilience depends on multiple forms of social capital, including robust networks among individuals and various communities: the local population and patients, local health care providers, residency faculty, and RTTs in general. The small size and remoteness of RTTs make them vulnerable to multiple challenges in finances, regulations, and accreditation, requiring program adaptability and suggesting the need for flexibility in the policies that govern them.

Maternal and Infant Health in Abu Dhabi: Insights from Key Informant Interviews.

Consequent upon rapid development in Abu Dhabi, there has been a rise in chronic disease, the susceptibilities to which are influenced by events occurring in early life. Hence, maternal and infant health are key areas in public health policy. Following a study of maternal and infant health in a cohort of mothers in Abu Dhabi between 2002 and 2004, seven key informant interviews were undertaken to elucidate the study findings through the impressions of Emirati women in positions within the healthcare area—including ministries, hospitals, and universities in Abu Dhabi. Semi-structured interviews were based on five key questions that covered the cultural responsiveness of the maternal health services—breastfeeding, health education, and physical and recreational activity. The responses were analysed using a thematic content technique and indicated that the status of women, cultural beliefs and practices, limited health knowledge, and language differences between the local population, healthcare providers, and health promoting materials were important themes. The study highlighted areas for future research and policy, including the communication gaps between healthcare professionals and women, the influences of advertising and the media on health issues, heath education, and ways to increase women’s participation in physical exercise. It is vital to consider non-medical determinants of health alongside biomedical determinants, to help develop culturally appropriate health strategies for this population.

Ebola in eastern DRC

Ebola in eastern DRC

Overcoming Barriers to Accessing Obstetric Care in Underserved Communities

Changes in the current workforce of obstetrician-gynecologists and other health care providers of obstetric care, as well as changes in the delivery of health care services, prompt health care leaders to consider alternative strategies for approaching the essential shortage of obstetric care providers and facilities. Geographic variations in health care needs and resources require a tailored approach by individual communities and local health care providers. New and emerging technologies can support a range of innovative solutions to health care access limitations. This article describes an alternative model for remote obstetric care and quality review in Santa Fe, New Mexico, that is applicable to any community facing limited access to full-spectrum obstetric care.

Building Immigration-Informed, Cross-Sector Coalitions: Findings from the Los Angeles County Health Equity for Immigrants Summit.

In December 2017, the Los Angeles County Office of Immigrant Affairs and Board of Supervisors, alongside local health care and legal providers, convened the Health Equity for Immigrants and Families Summit to advance a vision for immigrant health. We describe the four critical concepts identified by stakeholders to address the varied needs of immigrants in an increasingly anti-immigrant political environment: (1) Recognizing immigration status as a modifiable social determinant of health; (2) Adopting the concept of “Immigration-Informed Care” within health care institutions; (3) Establishing immigration-focused medical-legal partnerships; and (4) Building coordinated systems based on knowledge of local stakeholders, policies, and funding mechanisms.

If I was more informed about what exactly they do: perceptions of Botswana district hospital healthcare providers about World Spine Care

BackgroundIn 2011, World Spine Care (WSC) opened their pilot clinic at the Botswana Mahalapye District Hospital (MDH) aiming to develop a low-cost model of evidence-based spine care for underserved communities. Providing sustainable, integrated, evidence-based care will require buy-in from local healthcare providers (HCPs) and the communities served. The purpose of this project was to understand how MDH HCPs perceive WSC.MethodsWe used a qualitative descriptive methodology to conduct individual, semi-structured interviews with MDH HCPs who had some familiarity about WSC services. Interviews were conducted in English, audio-recorded, and transcribed verbatim. We used an iterative coding process for thematic content analysis and interpretations were regularly reviewed by all co-authors.ResultsIn March 2017, interviews with 20 HCPs, from diverse disciplines with a range in years’ experience at MDH, revealed three overlapping themes: knowledge about WSC and spinal related disorders, perceived role of WSC, and challenges for WSC integration. Participants who attended WSC conferences or self-referred for care were more informed and, generally, held positive perceptions. Participants lacked knowledge about managing spinal-related disorders, asserted hospital protocols did not meet patient needs, and perceived WSC is ‘filling a gap’ to manage these conditions. There were mixed perceptions about care received as WSC patients; some ultimately obtained relief, while others reported the treatment painful and unfamiliar, discharging themselves from care. Challenges to integrate WSC into the healthcare system were: lack of knowledge about scope of practice and unclear referral pathways; reversing the isolated care WSC provides by increasing collaboration between WSC and hospital staff; and, high turnover of WSC clinicians that undermines program sustainability.ConclusionsMDH healthcare providers had adequate general knowledge about World Spine Care and spinal-related disorders, but did not understand the WSC scope of practice nor referral pathways to and from providers. Participants advocated for greater collaboration between WSC and hospital staff to increase acceptance and integration to deliver spine care services and foster wider adoption of the WSC model, particularly if WSC expands services across Botswana. Future efforts that incorporate interviews with patients and government officials also can provide valuable perspectives to achieve sustainable, integrated, evidence-based spine care.

Provider Education About Pneumococcal Vaccination Practices for Older Adults

OBJECTIVE: To describe an interdisciplinary academic detailing project implemented to address low pneumococcal immunization rates. SETTING: Two medical clinics and four community pharmacies in rural Washington state. PRACTICE DESCRIPTION: The two medical clinics and four community pharmacies were all located in two rural counties and serve geographically large rural areas. PRACTICE INNOVATION: Academic detailing is an evidence-based approach designed to change clinical practice and improve decision-making. Our team utilized the academic detailing model to provide educational outreach to local rural health care providers. The detailing team visited each clinic and pharmacy on a defined schedule and provided information to physicians, clinic administrators, nurses, pharmacists, pharmacy technicians, medical assistants, and clinic front-end staff. MAIN OUTCOME MEASUREMENTS: The project team maintained detailed field notes from each academic detailing the visit and met to debrief about each encounter. From the field notes, through the process of thematic analysis and analytic memoing, the project team produced a list of "lessons learned" that could be used to guide other interprofessional teams wishing to embark on an academic detailing project. RESULTS: We have identified four key "lessons learned": Interprofessional team members bring different strengths to the project; using same-discipline team members paved the way for success; involving students aids in educating future practitioners in interprofessional practice; and scheduling meetings in advance is important. CONCLUSION: We described an approach to enhanced academic detailing using interprofessional team delivery, bringing interprofessional practice into the real-world practice setting.

Provider Education About Pneumococcal Vaccination Practices for Older Adults.

OBJECTIVE: To describe an interdisciplinary academic detailing project implemented to address low pneumococcal immunization rates. SETTING: Two medical clinics and four community pharmacies in rural Washington state. PRACTICE DESCRIPTION: The two medical clinics and four community pharmacies were all located in two rural counties and serve geographically large rural areas. PRACTICE INNOVATION: Academic detailing is an evidence-based approach designed to change clinical practice and improve decision-making. Our team utilized the academic detailing model to provide educational outreach to local rural health care providers. The detailing team visited each clinic and pharmacy on a defined schedule and provided information to physicians, clinic administrators, nurses, pharmacists, pharmacy technicians, medical assistants, and clinic front-end staff. MAIN OUTCOME MEASUREMENTS: The project team maintained detailed field notes from each academic detailing the visit and met to debrief about each encounter. From the field notes, through the process of thematic analysis and analytic memoing, the project team produced a list of "lessons learned" that could be used to guide other interprofessional teams wishing to embark on an academic detailing project. RESULTS: We have identified four key "lessons learned": Interprofessional team members bring different strengths to the project; using same-discipline team members paved the way for success; involving students aids in educating future practitioners in interprofessional practice; and scheduling meetings in advance is important. CONCLUSION: We described an approach to enhanced academic detailing using interprofessional team delivery, bringing interprofessional practice into the real-world practice setting.

Safety measures for nurses working abroad

Safety measures for nurses working abroad

SAT-038 HEMODIALYSIS IN BURUNDI: DATA AND CHALLENGES

The incidence of end-stage renal disease (ESRD) is increasing worldwide at an annual growth rate of 8%. In Sub-Saharan Africa, economic and manpower factors dictate a conservative approach to therapy in most instances. The majority of those with ESRD perish because of the lack of funds, as very few can afford regular maintenance dialysis and renal transplantation is often not available. Hemodialysis remains the most common modality of management, with a very few units offering peritoneal dialysis. Chronic hemodialysis became available in Burundi in July 2014 commenced in a private unit. The country has now 6 dialysis units situated in one city, Bujumbura. Four units are in public hospitals and two in private clinics. This is a retrospective study.The data were extracted from the African Renal Registry on Burundi. All chronic hemodialysis patients from 2014 to 2017 were included. Their characteristics were analyzed with the aim of to determine the etiology, status and challenges of dialysis in Burundi. From 2014 to 2017, 65 patients have been treated by chronic hemodialysis in Burundi. There were 56 men (86.1%). The mean age was 52.16 years. Forty-eight patients (73.8%) were followed in a private unit and 28 (26.2%) in public units. The prevalence for 2017 of patients on renal replacement treatment (RRT) was 1.6 per million population. The etiology of end stage renal disease was diabetes mellitus (32.3%), hypertension (30.7%), glomerulonephritis (10.8%), cystic kidney disease (1.5%) and unknown (21.7%). The seropositive rate for hepatitis B virus was 4.6%, for hepatitis C virus 18.5% and for HIV 9.2%. The initial modality treatment was hemodialysis (98.5%) and peritoneal dialysis (1.5%). The frequency distribution of initial vascular access types was 40.6% for femoral, 59.4% for internal jugular catheter and 0% for arteriovenous fistula. The RRT vintage was 1.5 years, and majority 60% were undergoing dialysis twice, 27.7% thrice dialysis and 12.3 % only single dialysis session per week. The main complications were catheter infection (60%) and acute pulmonary edema (19%). The mortality rate was 77.7%, and 7 patients abandoned dialysis due to financial matter. The prevalence and outcomes associated with dialysis in Burundi are influenced by the following: absence of governement funding for dialysis, gross shortage of nephrologists, dialysis nurses, and technicians, lack of educational initiatives to promote dialysis, no establish health insurance to support dialysis definitely. To run dialysis in Burundi is a challenge. Our recommendations based on these observation include optimizing dialysis treatment initiatives and integrating them with other health strategies, as well as training of local health care providers, re-use of dialyzers to cut costs, implementation of a National Kidney Foundation to fund dialysis and a National Health Policy to prevent hypertension and diabetes.