Non-physician Healthcare Workers Research Articles

A multifaceted strategy using mobile technology to assist rural primary healthcare doctors and frontline health workers in cardiovascular disease risk management: protocol for the SMARTHealth India cluster randomised controlled trial

BackgroundBlood Pressure related disease affected 118 million people in India in the year 2000; this figure will double by 2025. Around one in four adults in rural India have hypertension, and of those, only a minority are accessing appropriate care. Health systems in India face substantial challenges to meet these gaps in care, and innovative solutions are needed.MethodsWe hypothesise that a multifaceted intervention involving capacity strengthening of primary healthcare doctors and non-physician healthcare workers through use of a mobile device-based clinical decision support system will result in improved blood pressure control for individuals at high risk of a cardiovascular disease event when compared with usual healthcare. This intervention will be implemented as a stepped wedge, cluster randomised controlled trial in 18 primary health centres and 54 villages in rural Andhra Pradesh involving adults aged ≥40 years at high cardiovascular disease event risk (approximately 15,000 people). Cardiovascular disease event risk will be calculated based on World Health Organisation/International Society of Hypertension’s region-specific risk charts. Cluster randomisation will occur at the level of the primary health centres. Outcome analyses will be conducted blinded to intervention allocation.Expected outcomesThe primary study outcome is the difference in the proportion of people meeting guideline-recommended blood pressure targets in the intervention period vs. the control period. Secondary outcomes include mean reduction in blood pressure levels; change in other cardiovascular disease risk factors, including body mass index, current smoking, reported healthy eating habits, and reported physical activity levels; self-reported use of blood pressure and other cardiovascular medicines; quality of life (using the EQ-5D); and cardiovascular disease events (using hospitalisation data). Trial outcomes will be accompanied by detailed process and economic evaluations.SignificanceThe findings are likely to inform policy on a scalable strategy to overcome entrenched inequities in access to effective healthcare for under-served populations in low and middle income country settings.Trial registrationClinical Trial Registry India CTRI/2013/06/003753.

Screening for HIV‐associated peripheral neuropathy in resource‐limited settings

Peripheral neuropathy is the most common neurological complication of human immunodeficiency virus (HIV) infection but is widely under-diagnosed in resource-limited settings. We investigated the utility of screening tools administered by nonphysician healthcare workers (HCW) and quantitative sensory testing (QST) administered by trained individuals for identification of moderate/severe neuropathy. We enrolled 240 HIV-infected outpatients using 2-stage cluster randomized sampling. HCWs administered the several screening tools. Trained study staff performed QST. Tools were validated against a clinical diagnosis of neuropathy. Participants were 65% women, mean age 36.4 years, median CD4 324 cells/μL. A total of 65% were taking antiretrovirals, and 18% had moderate/severe neuropathy. The screening tests were 76% sensitive in diagnosing moderate/severe neuropathy with negative predictive values of 84-92%. QST was less sensitive but more specific. Screening tests administered by HCW have excellent negative predictive values and are promising tools for scale-up in resource-limited settings. QST shows promise for research use.

Health care worker attitudes about clinical trials at a comprehensive cancer center.

e20633 Background: Cancer patient (pt) participation in clinical trials (CT) is low. Little is known about the beliefs and attitudes of health care workers (HCW) and how they impact intention to discuss CT with pts. The overall goal of this project was to develop a conceptual model to guide future interventions to enhance communication about CT between HCW and cancer pts. Methods: Two email surveys of non-physician HCW at an NCI-designated comprehensive cancer center were conducted. The first was sent to a random sample of 150 HCW. The second was sent to 80 who completed the first survey. Based on our prior work (Eads et al. ASCO 2011) and Ajzen’s Theory of Planned Behavior, domains of the first included CT knowledge (19 items, agree/disagree) and attitudes (27 items, 5-point Likert); the second included normative beliefs about institutional attitudes toward CT (6 items, 5-point Likert), self-efficacy about engaging in discussion about CT (14 items, 5-point Likert), and intention to discuss CT with pts (4 items, 7-point Likert). Results: 41 HCW completed both anonymous surveys; 27 could be matched by demographics. Median age of matched respondents was 44.3 yrs (range 24-63), 26 female, 22 caucasian, 9 nurses. Overall, CT knowledge was high (median 17/19 items correct). There were strong associations between attitudes and self-efficacy (Spearman r=-0.425, p=0.03), as well as perceived normative beliefs and self-efficacy (r=0.651, p=0.0002). These associations were strong amongst nurses (r=-0.818, p=0.007 and r=0.656, p=0.05, respectively), with a particularly strong correlation between self-efficacy and intention to discuss clinical trials with pts (r=0.891, p=0.001). Conclusions: In spite of a small sample size, these pilot data strongly support a behavioral framework to understand and address the impact of HCW attitudes and beliefs about CT on discussions of CT with pts. Insofar as HCW (especially nurses) have substantial pt contact, and serve as a resource for pts regarding treatment decisions, educational interventions to address HCW barriers to discussing CT with pts (i.e. attitudes, beliefs, and self-efficacy) could positively impact pt attitudes and improve decision making.

Understanding Policy Is the Medical Director's Best Practice

Understanding Policy Is the Medical Director's Best Practice

Training needs and evaluation of a neuro-HIV training module for non-physician healthcare workers in Western Kenya

BackgroundRecent efforts to improve neurological care in resource-limited settings have focused on providing training to non-physician healthcare workers. MethodsA one-day neuro-HIV training module emphasizing HIV-associated dementia (HAD) and peripheral neuropathy was provided to 71 health care workers in western Kenya. Pre- and post-tests were administered to 55 participants. ResultsMean age of participants was 29years, 53% were clinical officers and 40% were nurses. Self-reported comfort was significantly higher for treating medical versus neurologic conditions (p<0.001). After training, participants identified more neuropathy etiologies (pre=5.6/9 possible correct etiologies; post=8.0/9; p<0.001). Only 4% of participants at baseline and 6% (p=0.31) post-training could correctly identify HAD diagnostic criteria, though there were fewer mis-identified criteria such as abnormal level of consciousness (pre=82%; post=43%; p<0.001) and hallucinations (pre=57%; post=15%; p<0.001). ConclusionsHealthcare workers were more comfortable treating medical than neurological conditions. This training significantly improved knowledge about etiologies of neuropathy and decreased some misconceptions about HAD.

Provider Detailing: An Intervention to Decrease Prescription Opioid Deaths in Utah: Table 1

Utah undertook a multipronged effort to reverse an epidemic of deaths among patients taking prescription opioids. This article describes the provider detailing portion of the effort. Presentations highlighting six recommended prescribing practices were developed and presented to health care workers. Participants were encouraged to utilize the state prescription database and to complete a series of surveys assessing confidence and behavior changes at 0, 1, and 6 months post-presentation. Continuing medical education credits incentivized participation. Utah's medication-related overdose deaths dropped 14.0% in 2008 compared with 2007 following program implementation. A total of 581 physicians and numerous nonphysician health care workers were reached during 46 presentations. Follow-up surveys regarding the degree of adoption of practice changes were completed by 366 participants at 0 months, 82 participants at 1 month, and 29 participants at 6 months. Combined results for all three evaluations showed that 60-80% of responding providers reported no longer prescribing long-acting opioids for acute pain or with sedatives; 50% noted using Utah's controlled substances database during patient care and utilizing lower starting doses and slower escalations; and 30-50% reported obtaining EKGs and sleep studies on appropriate patients, using patient education tools, and implementing Utah's prescribing guidelines. Provider detailing was associated with a decrease in Utah's prescription opioid death rate and improvements in provider self-reported prescribing behaviors. Other simultaneous interventions may have contributed to the decline in death rates. This intervention's effect was limited by short-term funding.

Utility of Quantitative Sensory Testing and Screening Tools in Identifying HIV-Associated Peripheral Neuropathy in Western Kenya: Pilot Testing

Background/AimNeuropathy is the most common neurologic complication of HIV but is widely under-diagnosed in resource-constrained settings. We aimed to identify tools that accurately distinguish individuals with moderate/severe peripheral neuropathy and can be administered by non-physician healthcare workers (HCW) in resource-constrained settings.MethodsWe enrolled a convenience sample of 30 HIV-infected outpatients from a Kenyan HIV-care clinic. A HCW administered the Neuropathy Severity Score (NSS), Single Question Neuropathy Screen (Single-QNS), Subjective Peripheral Neuropathy Screen (Subjective-PNS), and Brief Peripheral Neuropathy Screen (Brief-PNS). Monofilament, graduated tuning fork, and two-point discrimination examinations were performed. Tools were validated against a neurologist's clinical assessment of moderate/severe neuropathy.ResultsThe sample was 57% male, mean age 38.6 years, and mean CD4 count 324 cells/µL. Neurologist's assessment identified 20% (6/30) with moderate/severe neuropathy. Diagnostic utilities for moderate/severe neuropathy were: Single-QNS - 83% sensitivity, 71% specificity; Subjective-PNS-total - 83% sensitivity, 83% specificity; Subjective-PNS-max and NSS - 67% sensitivity, 92% specificity; Brief-PNS - 0% sensitivity, 92% specificity; monofilament - 100% sensitivity, 88% specificity; graduated tuning fork - 83% sensitivity, 88% specificity; two-point discrimination - 75% sensitivity, 58% specificity.ConclusionsPilot testing suggests Single-QNS, Subjective-PNS, and monofilament examination accurately identify HIV-infected patients with moderate/severe neuropathy and may be useful diagnostic tools in resource-constrained settings.

Closing Gaps in Antiretroviral Therapy Access: Human Immunodeficiency Virus–Associated Dementia Screening Instruments for Non-Physician Healthcare Workers

Human immunodeficiency virus-associated dementia (HIV-D) is an indication for antiretroviral therapy (ART), but HIV-D is not routinely screened for in ART clinics in sub-Saharan Africa. Given the dearth of physicians in sub-Saharan Africa, enabling non-physician healthcare workers to identify HIV-D is crucial for early treatment initiation and preventing chronic neurologic disability. Non-physician healthcare workers administered locally adapted screening instruments to 48 persons living with acquired immunodeficiency syndrome (PLWAs), and 15 healthy comparison persons provided normative data. Stage IV PLWAs performed worse than the comparison group on all tests. Overall, 24 (50%) of 48 PLWAs had significant cognitive impairment. Among HIV staging categories, 1 stage II (33%), 6 stage III (42%), and 17 stage IV (55%) patients were identified as cognitively impaired. Our pilot study indicates that screening instruments used by non-physician healthcare workers can identify cognitive impairment in PLWAs and may facilitate appropriate initiation of ART in resource-poor settings.

Integrating cervical cancer prevention in HIV/AIDS treatment and care programmes

Peckham and Hann’s call for integrating cervical cancer prevention as part of broader sexual and reproductive health prevention services1 is especially relevant to sub-Saharan Africa where both cervical cancer and sexually transmitted infections, especially HIV/AIDS, are widely prevalent. Over the past decade, successful HIV/AIDS care and treatment programmes have been instituted in over a dozen hardest-hit sub-Saharan African countries, largely through bilateral and multilateral programmes like the United States President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria.2 HIV-infected women are at heightened risk for pre-invasive and invasive neoplasia of the cervix.3,4 HIV/AIDS care and treatment programmes thus provide an ideal platform to integrate cervical cancer prevention activities in countries which face a dual burden of both AIDS and cervical cancer, an AIDS-defining disease. With steady donor support over the past 5 years, these programmes are slowly but steadily contributing to the development of health-care service delivery capacity in emerging nations by establishing infrastructures, training the health-care work force, and tackling complex and challenging problems in implementation and scale-up.5 Limited access to cervical cancer prevention services, the usual circumstance for women in low-resource environments, serves as a counterforce to the life-prolonging potential of increased access to affordable antiretroviral therapy. Cervical cancer prevention strategies that use visual inspection with acetic acid (VIA) and same-visit cryotherapy (“see-and-treat”) are cost-effective alternatives to cytology-based screening programmes. These procedures can be performed by nurses and other non-physician health-care workers and allow screening and treatment to be linked to the same clinic visit. Our experience in Zambia has shown that VIA-based prevention services that are nested within the context of antiretroviral therapy programmes allow early detection of cervical cancer in high-risk HIV-infected women in a cost-effective way.6,7 It also allows opportunities for the provision of broader gynaecologic and other health care for women. Eventual integration of low-cost, rapid screening tests for detecting human papillomavirus within VIA-based screening services will additionally increase programmatic efficiency. When cervical cancer prevention services are offered to HIV-infected women in a venue attended by non-HIV-infected women, a scalable intervention is established that can reach out to all women regardless of HIV status. Horizontal and diagonal collaborations between agencies and individuals focusing on HIV/AIDS care and cancer prevention could open new vistas for expanding availability of care for women at risk of one or both of these conditions, thereby ensuring wider programme impact. The conjoint contributions of such collaborations may be larger than the sum of their parts. ■

Can non-physician health-care workers assess and manage cardiovascular risk in primary care?

To ascertain the reliability of applying the WHO Cardiovascular Risk Management Package by non-physician health-care workers (NPHWs) in typical primary health-care settings. Based on an a priori 80% agreement level between the NPHWs and the "expert" physicians (gold standard), 649 paired (matched) applications of the protocol were obtained for analysis using Kappa statistic and multivariate logit regression. Results indicate over 80% agreement between raters, from moderate to perfect levels of agreement in almost all of the sections in the package. The odds of obtaining a difference between raters and a benchmark are not statistically significant. Applying the WHO Cardiovascular Risk Management Package, NPHWs can be retrained to reliably and effectively assess and manage cardiovascular risks in primary health-care settings where there are no attending physicians. The package could be a useful tool for scaling up the management of cardiovascular diseases in primary health care.

Zambian health care workers’ knowledge, attitudes, beliefs, and practices regarding epilepsy

Objective Zambia suffers from a physician shortage, leaving the provision of care for those with epilepsy to nonphysician health care workers who may not be adequately trained for this task. These individuals are also important community opinion leaders. Our goal in this study was to determine the knowledge, attitudes, beliefs, and practices of these health care workers with respect to epilepsy. Methods Health care workers in urban and rural districts of Zambia completed a self-administered, 48-item questionnaire containing items addressing demographics, personal experience with epilepsy, social tolerance, willingness to provide care, epilepsy care knowledge, and estimates of others’ attitudes. Analyses were conducted to assess characteristics associated with more epilepsy care knowledge and social tolerance. Results The response rate was 92% ( n = 276). Those who had received both didactic and bedside training ( P = 0.02) and more recent graduates ( P = 0.007) had greater knowledge. Greater knowledge was associated with more social tolerance ( P = 0.005), but having a family member with epilepsy was not ( P = 0.61). Health care workers were generally willing to provide care to this patient population, but ∼25% would not allow their child to marry someone with epilepsy and 20% thought people with epilepsy should not marry or hold employment. Respondents reported that people with epilepsy are feared and/or rejected by both their families (75%) and their community (88.8%). Conclusions Knowledge gaps exist particularly in acute management and recognition of partial epilepsy. More recent graduates were more knowledgeable, suggesting that curriculum changes instituted in 2000 may be improving care. Health care workers expressed both personal and professional reservations about people with epilepsy marrying. In addition to improving diagnosis and treatment skills, educational programs must address underlying attitudes that may worsen existing stigmatizing trends.

Telemedicine by email in remote Cambodia

An email-based telemedicine service was implemented in two remote village communities in Cambodia. Volunteer physicians at the Brigham and Women's Hospital, Massachusetts General Hospital and the Sihanouk Hospital Center of Hope in Phnom Penh provide monthly consultations to the local clinicians. Between February 2001 and May 2005, there were 469 teleconsultations. The 214 telemedicine cases involving new patients managed in the first 28 months were reviewed. The mean duration of the chief complaint at the initial patient visit was 37 months for the first six months and had dropped to eight months by the end of the study period. Of 63 adult patients surveyed, all were either satisfied (54%, n = 34) or very satisfied (46%, n = 29) with their experience in the telemedicine clinic. About 78% (n = 49) were willing to pay, on average, 0.63 US dollars for their visits. The introduction of basic point-of-care laboratory testing in November 2004 was associated with a reduction in patients requiring off-site referral for completion of laboratory testing (69% before to 35% afterwards, P < 0.001). The success of the pilot telemedicine programme confirms the value of email support for non-physician health-care workers in the developing world.

Delivering Health Care in Rural Cambodia via Store-and-Forward Telemedicine: A Pilot Study

Since 2001, a monthly telemedicine clinic has helped provide health care to residents in a remote region in Cambodia. Physicians at Massachusetts General Hospital and Brigham and Women's Hospital in Boston, Massachusetts, and Sihanouk Hospital of HOPE in Phnom Penh, Cambodia, provide consultations via e-mail to a mobile nurse in the district of Rovieng, Cambodia. We describe the operations of the monthly clinic and report the results of a retrospective case review of the first 28 months of consultations. We also report the results of a satisfaction and willingness to pay survey. A total of 264 visits were made during the 28 monthly sessions. Mean duration of chief complaint at initial visit declined from 37 months to 8 months during the first and last 6 months of the study period, respectively. Thirty-six percent (n = 76) of new patients complained of abdominal pain. Nine percent (n = 20) of new patients were given an empiric diagnosis of goiter. The percent of patients requiring referral to a hospital outside of the village decreased over time. All patients surveyed were either "very satisfied" or "satisfied" with their care, and most patients were willing to pay for a visit, with a median amount of USD 0.63. We conclude that store-and-forward e-mail consultative support for mobile nonphysician health care workers is a feasible model for delivering care in the developing world. Further research is needed to demonstrate improvement in health status, cost effectiveness, and sustainability.

Anesthesiologists and the education of dentists (and others) in anesthesia.

Since the beginning of the modern era of anesthesia practice in the mid-19th century, dentists have been involved in the practice of anesthesia. Both Horace Wells, who recognized the beneficial anesthetic effect of nitrous oxide, and William Thomas Green Morton, who in 1846 made the first public demonstration of ether anesthesia, were dentists. following discussion will seek to review the current training of dentists in anesthesia practice as well as discuss the role of physician anesthesiologists in this training and practice. An overview of the training of other physicians and non-physician health care workers in aspects of sedation, analgesia, and airway management will also be included. In 1977 Klein, Wollman, and Cohen 1 published an article in Anesthesiology in which they reviewed the practice of anesthesia by dentists. They proposed that anesthesiology training programs should help to improve the quality of dental anesthesia practice by providing anesthesia training to dentists. They said: It is the opinion of the authors that it would benefit the profession of dentistry and the quality of outpatient dental anesthesia in this country in a positive manner if there were formally set aside a small number of anesthesia residencies for dental applicants who have good academic qualifications and show a desire for teaching and research on a dental school faculty. Anesthesia practice among dentists can include nitrous oxide sedation, oral sedation, combined oral and inhaled sedation, intravenous conscious sedation, deep sedation, and general anesthesia. American Dental Association (ADA) has formulated a policy statement about the use of sedation and general anesthesia in dentistry. policy states: The use of conscious sedation, deep sedation, and general anesthesia in dentistry is safe and effective when properly administered by trained individuals. American Dental Association strongly supports the right of appropriately trained dentists to use these modalities for the management of dental patients and is committed to ensuring their safe and effective use.

Telesonography

Ultrasound (US) is a burgeoning diagnostic tool and is often the only available imaging modality in low- and middle-income countries (LMICs). However, bedside providers often lack training to acquire or interpret US images. We conducted a study to determine if a remote tele-intensivist could mentor geographically removed LMIC providers to obtain quality and clinically useful US images.Nine Haitian non-physician health care workers received a 20-minute training on basic US techniques. A volunteer was connected to an intensivist located in the USA via FaceTime. The intensivist remotely instructed the non-physicians to ultrasound five anatomic sites. The tele-intensivist evaluated the image quality and clinical utility of performing tele-ultrasound in a LMIC.The intensivist agreed (defined as “agree” or “strongly agree” on a five-point Likert scale) that 90% (57/63) of the FaceTime images were high quality. The intensivist felt comfortable making clinical decisions using FaceTime images 89% (56/63) of the time.Non-physicians can feasibly obtain high-quality and clinically relevant US images using video chat software in LMICs. Commercially available software can connect providers in institutions in LMICs to geographically removed intensivists at a relatively low cost and without the need for extensive training of local providers.

Using students' perceptions of internal medicine teachers' professionalism.

Objective: Curricular initiatives and evaluation systems have been developed to enhance and reinforce the importance of professional behaviors among medical students. A critical aspect of student learning is exposure to role models who exhibit the highest standards of professionalism. Several articles have addressed the evaluation of students' behaviors and the problems with professional development among trainees, but less has been written about students' perceptions of the professional behaviors of their preceptors. We developed a process for identifying problems in preceptors' behaviors and for giving feedback and appropriate faculty development in professionalism. Description: Our internal medicine clerkship is an eight-week inpatient experience. After each four—week ward assignment, the students are required to evaluate their faculty and supervising residents. A section on professionalism was added to the evaluation form for the 1999–2000 academic year as a way to identify possible problems in resident and faculty behaviors. Seven response items, each beginning with the statement “I observed my faculty/housestaff …” address these issues: making derogatory statements about patients or their families; making derogatory statements about other services; discussing confidential information in public; inappropriately withholding information or intentionally giving incorrect information to a patient; using disrespectful terminology to describe patients; treating non-physician healthcare workers inappropriately; and demonstrating specific behavior toward a patient because of lifestyle or ethnic, religious, or socioeconomic background. The students responded to each statement using a five-point scale of never, rarely, occasionally, frequently, and consistently. Also, space for written comments was provided. The results from evaluations of 412 faculty and 443 housestaff were reviewed in order to study their behavior. The unprofessional behavior most commonly identified by the students for each group was the use of derogatory comments in discussing other services. The use of derogatory comments about patients and the use of disrespectful terminology to describe patients were the other behaviors most frequently reported. Discussion: These student evaluations of their faculty and supervising housestaff have provided the information needed to plan feedback and faculty development. The majority of problems identified involved the use of unprofessional language and derogatory comments in various contexts. According to the students' written comments, the unprofessional remarks were often made casually. It is possible that the preceptors do not recognize that their informal comments might be perceived as objectionable and unprofessional. Collecting information about students' perceptions of the professional behaviors of faculty has proved to be useful and practical. The information is now being studied as part of all the school's year-three clinical clerkships. Through identification of problem areas and focused intervention, we hope to continue to optimize the professional atmosphere of our learning environment.