Non-specialist Healthcare Providers Research Articles

Von Willebrand disease.

von Willebrand disease (VWD) is the most common inherited bleeding disorder. The disorder is characterized by excessive mucocutaneous bleeding. The most common bleeding manifestations of this condition include nosebleeds, bruising, bleeding from minor wounds, menorrhagia or postpartum bleeding in women as well as bleeding after surgery. Other less frequent symptoms include gastrointestinal bleeding, haematomas or haemarthroses. VWD pathophysiology is complex and results from defects in von Willebrand factor (VWF) glycoprotein. Quantitative deficiencies are responsible for type 1 VWD with a partial decrease of VWF and type 3 with the complete absence of VWF. Qualitative abnormalities cause type 2 VWD, being further divided into types 2A, 2B, 2M and 2N. Although common, VWD is at risk of misdiagnosis, overdiagnosis and underdiagnosis owing to several factors, including complex diagnosis, variability of bleeding symptoms, presence of external variables (blood groups and other physiological modifiers such as exercise, thyroid hormones, oestrogens, and ageing), and lack of disease awareness among non-specialist health-care providers. Establishing the correct VWD diagnosis requires an array of specialized phenotypic assays and/or molecular genetic testing of the VWF gene. The management of bleeding includes increasing endogenous VWF levels with desmopressin or infusion of exogenous VWF concentrates (plasma-derived or recombinant). Fibrinolytic inhibitors, topical haemostatic agents and hormonal therapies are used as effective adjunctive measures.

ChatGPT on guidelines: Providing contextual knowledge to GPT allows it to provide advice on appropriate colonoscopy intervals.

Colonoscopy is commonly used in screening and surveillance for colorectal cancer. Multiple different guidelines provide recommendations on the interval between colonoscopies. This can be challenging for non-specialist healthcare providers to navigate. Large language models like ChatGPT are a potential tool for parsing patient histories and providing advice. However, the standard GPT model is not designed for medical use and can hallucinate. One way to overcome these challenges is to provide contextual information with medical guidelines to help the model respond accurately to queries. Our study compares the standard GPT4 against a contextualized model provided with relevant screening guidelines. We evaluated whether the models could provide correct advice for screening and surveillance intervals for colonoscopy. Relevant guidelines pertaining to colorectal cancer screening and surveillance were formulated into a knowledge base for GPT. We tested 62 example case scenarios (three times each) on standard GPT4 and on a contextualized model with the knowledge base. The contextualized GPT4 model outperformed the standard GPT4 in all domains. No high-risk features were missed, and only two cases had hallucination of additional high-risk features. A correct interval to colonoscopy was provided in the majority of cases. Guidelines were appropriately cited in almost all cases. A contextualized GPT4 model could identify high-risk features and quote appropriate guidelines without significant hallucination. It gave a correct interval to the next colonoscopy in the majority of cases. This provides proof of concept that ChatGPT with appropriate refinement can serve as an accurate physician assistant.

Interpretable Skin Cancer Classification based on Incremental Domain Knowledge Learning.

The recent advances in artificial intelligence have led to the rapid development of computer-aided skin cancer diagnosis applications that perform on par with dermatologists. However, the black-box nature of such applications makes it difficult for physicians to trust the predicted decisions, subsequently preventing the proliferation of such applications in the clinical workflow. In this work, we aim to address this challenge by developing an interpretable skin cancer diagnosis approach using clinical images. Accordingly, a skin cancer diagnosis model consolidated with two interpretability methods is developed. The first interpretability method integrates skin cancer diagnosis domain knowledge, characterized by a skin lesion taxonomy, into model development, whereas the other method focuses on visualizing the decision-making process by highlighting the dominant of interest regions of skin lesion images. The proposed model is trained and validated on clinical images since the latter are easily obtainable by non-specialist healthcare providers. The results demonstrate the effectiveness of incorporating lesion taxonomy in improving model classification accuracy, where our model can predict the skin lesion origin as melanocytic or non-melanocytic with an accuracy of 87%, predict lesion malignancy with 77% accuracy, and provide disease diagnosis with an accuracy of 71%. In addition, the implemented interpretability methods assist understand the model's decision-making process and detecting misdiagnoses. This work is a step toward achieving interpretability in skin cancer diagnosis using clinical images. The developed approach can assist general practitioners to make an early diagnosis, thus reducing the redundant referrals that expert dermatologists receive for further investigations.

Understanding factors that affect wellbeing in trans people “later” in transition: a qualitative study

PurposeAlthough cross-sectional studies have demonstrated that trans people present with lower quality of life and wellbeing than the general population, few studies have explored the factors associated with this, particularly in those who have medically transitioned some time ago. This paper aims to fill the gap in the literature on what factors are associated with wellbeing in trans people who initiated medical transition some time ago.MethodsThis study used semi-structured one-to-one interviews with 23 participants to investigate the factors that impact upon the wellbeing of trans people who had initiated Gender Affirming Medical Treatment five or more years ago. The content of the interviews were analysed with an inductive, grounded theory approach to identify common themes within them.ResultsThe four themes identified include some consistencies with cisgender populations (while being viewed through the lens of trans experience), as well as those more specific to the trans experience. Together these themes were: Interactions with healthcare services; Seeking societal acceptance; Quality of social support; The ‘double-edged sword’ of media and social media. Each of the themes identifies a factor that participants highlighted as impacting, either positively or negatively, on their wellbeing.ConclusionsThe results highlight the importance of social support, protective legislations, awareness of trans issues in the general public, and the need of improving the knowledge held by non-specialist healthcare providers.

Gaining consensus: the challenges of living with a stoma and the impact of stoma leakage.

People with a stoma face many unique challenges. Leakage is a significant one but is not sufficiently discussed within the wider area of health and social care. This study aimed to articulate and achieve consensus on the problems experienced by people with a stoma, particularly leakage, in the hope of encouraging conversations among patients, clinicians and policymakers on how to solve them. Output from a modified Delphi panel, consisting of patient groups, was used to create a set of calls to action, with a particular focus on the issue of leakage. Leakage has a large impact on daily life and can cause both physical and mental health difficulties. Peer support and specialist care can be offer considerable benefits in dealing with these. There are significant unmet needs for equitable access to specialist stoma care and peer support, as well as information provision for non-specialist healthcare providers. The calls to action should be implemented.

Primary Health Professionals\u2019 Beliefs, Experiences, and Willingness to Treat Minor-Attracted Persons

There is a desire and need among minor-attracted persons (MAPs) to access support within the community, and this often begins with an approach to healthcare providers working in general medical/mental health settings. However, little is known about the experiences of these non-specialist professionals in relation to their beliefs, knowledge, and decision-making processes when working with patients who disclose sexual attractions to children. Using an online survey, this study explored the knowledge, comfort, competence, and treatment willingness of 220 non-specialist healthcare providers when faced with patients who disclose sexual attractions to children. We investigated how often such disclosures were made, clinician stigma, treatment priorities, and professionals’ willingness to report MAPs to external agencies because of their sexual attractions. Some key differences were found when comparing primary medical vs. mental health professionals, including increased likelihood to view MAPs as dangerous, unable to control behaviors and that sexual attractions are an avoidable choice, in the former group. Both groups prioritized mental health treatment targets above controlling attractions and living with stigmatized attractions, although controlling or changing attractions were still relatively high priorities. Results indicated a need for further training, focusing on increasing comfort around working with MAPs, as this was associated with a greater willingness to work with this group. We identify current gaps in service provision for MAPs seeking professional support and discuss recommendations for professional training.

Group problem management plus (PM+) to decrease psychological distress among Syrian refugees in Turkey: a pilot randomised controlled trial

BackgroundSyrian refugees resettled in Turkey show a high prevalence of symptoms of mental disorders. Problem Management Plus (PM+) is an effective psychological intervention delivered by non-specialist health care providers which has shown to decrease psychological distress among people exposed to adversity. In this single-blind pilot randomised controlled trial, we examined the methodological trial procedures of Group PM+ (gPM+) among Syrian refugees with psychological distress in Istanbul, Turkey, and assessed feasibility, acceptability, perceived impact and the potential cost-effectiveness of the intervention.MethodsRefugees with psychological distress (Kessler Psychological Distress Scale, K10 > 15) and impaired psychosocial functioning (World Health Organization Disability Assessment Schedule, WHODAS 2.0 > 16) were recruited from the community and randomised to either gPM+ and enhanced care as usual (E-CAU) (n = 24) or E-CAU only (n = 22). gPM+ comprised of five weekly group sessions with eight to ten participants per group. Acceptability and feasibility of the intervention were assessed through semi-structured interviews. The primary outcome at 3-month follow-up was symptoms of depression and anxiety (Hopkins Symptoms Checklist-25). Psychosocial functioning (WHODAS 2.0), symptoms of posttraumatic stress disorder and self-identified problems (Psychological Outcomes Profiles, PSYCHLOPS) were included as secondary outcomes. A modified version of the Client Service Receipt Inventory was used to document changes in the costs of health service utilisation as well as productivity losses.ResultsThere were no barriers experienced in recruiting study participants and in randomising them into the respective study arms. Retention in gPM+ was high (75%). Qualitative analyses of the interviews with the participants showed that Syrian refugees had a positive view on the content, implementation and format of gPM+. No adverse events were reported during the implementation. The study was not powered to detect an effect. No significant difference between gPM+ and E-CAU group on primary and secondary outcome measures, or in economic impacts were found.ConclusionsgPM+ delivered by non-specialist peer providers seemed to be an acceptable, feasible and safe intervention for Syrian refugees in Turkey with elevated levels of psychological distress. This pilot RCT sets the stage for a fully powered RCT.Trial registrationClinicalTrials.gov Identifier NCT03567083; date: 25/06/2018.

Role of accredited social health activists in treatment of persons with severe mental illness in the community.

Role of accredited social health activists in treatment of persons with severe mental illness in the community.

Understanding the health-care experiences of people with sickle cell disorder transitioning from paediatric to adult services: This Sickle Cell Life, a longitudinal qualitative study

Background Transitions from paediatric to adult health-care services cause problems worldwide, particularly for young people with long-term conditions. Sickle cell disorder brings particular challenges needing urgent action. Objectives Understand health-care transitions of young people with sickle cell disorder and how these interact with broader transitions to adulthood to improve services and support. Methods We used a longitudinal design in two English cities. Data collection included 80 qualitative interviews with young people (aged 13–21 years) with sickle cell disorder. We conducted 27 one-off interviews and 53 repeat interviews (i.e. interviews conducted two or three times over 18 months) with 48 participants (30 females and 18 males). We additionally interviewed 10 sickle cell disease specialist health-care providers. We used an inductive approach to analysis and co-produced the study with patients and carers. Results Key challenges relate to young people’s voices being ignored. Participants reported that their knowledge of sickle cell disorder and their own needs are disregarded in hospital settings, in school and by peers. Outside specialist services, health-care staff refuse to recognise patient expertise, reducing patients’ say in decisions about their own care, particularly during unplanned care in accident and emergency departments and on general hospital wards. Participants told us that in transitioning to adult care they came to realise that sickle cell disorder is poorly understood by non-specialist health-care providers. As a result, participants said that they lack trust in staff’s ability to treat them correctly and that they try to avoid hospital. Participants reported that they try to manage painful episodes at home, knowing that this is risky. Participants described engaging in social silencing (i.e. reluctance to talk about and disclose their condition for fear that others will not listen or will not understand) outside hospital; for instance, they would avoid mentioning cell sickle disorder to explain fatigue. Their self-management tactics include internalising their illness experiences, for instance by concealing pain to protect others from worrying. Participants find that working to stay healthy is difficult to reconcile with developing identities to meet adult life goals. Participants have to engage in relentless self-disciplining when trying to achieve educational goals, yet working hard is incompatible with being a ‘good adult patient’ because it can be risky for health. Participants reported that they struggle to reconcile these conflicting demands. Limitations Our findings are derived from interviews with a group of young people in England and reflect what they told us (influenced by how they perceived us). We do not claim to represent all young people with sickle cell disorder. Conclusions Our findings reveal poor care for young people with sickle cell disorder outside specialist services. To improve this, it is vital to engage with young people as experts in their own condition, recognise the legitimacy of their voices and train non-specialist hospital staff in sickle cell disorder care. Young people must be supported both in and outside health-care settings to develop identities that can help them to achieve life goals. Future work Future work should include research into the understanding and perceptions of sickle cell disease among non-specialist health-care staff to inform future training. Whole-school interventions should be developed and evaluated to increase sickle cell disorder awareness. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 44. See the NIHR Journals Library website for further project information.

Quality and Content of YouTubeTM Videos Related to Sinus Lift Surgery

ObjectiveIn the interest of supplying medical information to YouTubeTM videos, this study aimed to assess the quality and content of the information provided that is related to sinus lift surgery. MethodsIn this cross-sectional study, YouTubeTM videos were searched using the search term “sinus lift surgery”. The first 140 videos were reviewed and analyzed by two independent researchers, after which 103 of them were included in the study. A 13-point scale was used to classify the videos by low- and high-content. Each video was evaluated on content quality using the video information and quality index (VIQI). ResultsNinety-four (94.28%) and nine (8.72%) videos were included in the high-content and low-content groups, respectively. The high-content video group covered more topics than the low-content group, such as the definition of the procedure, its contraindications and advantages, and what to expect after the surgery (P < 0.05). The total VIQI scores of the high-score group were significantly higher than those of the low-score group. There was a positively strong correlation between total content score and VIQI (r = 0.777, P < 0.05). ConclusionThe quantity and quality of the YouTubeTM videos that feature sinus lift surgery are limited for professionals but may be sufficient for patients and non-specialist health care providers. Medical professionals, such as periodontists and oral surgeons, should play more of an active role in providing high-quality information by directing patients toward alternative sources that more clearly explain their surgeries.

Psychosocial Interventions for Perinatal Depression in China: A Systematic Review and Meta-Analysis

Background: The prevalence of perinatal depression is 16.3% in China and has shown a rising trend in the last decade. However, very few studies were found comparing and summarizing psychosocial interventions for perinatal depression. This study aimed at evaluating and characterizing psychosocial interventions for perinatal depression in Mainland China. Methods: In this systematic review and meta-analysis, ten major English and Chinese language electronic bibliographic databases were searched for randomized controlled trials examining the effect of psychosocial interventions for perinatal depressed women in Mainland China. Studies meeting eligibility criteria and published before 25th February 2019 were included, while those focusing on a very specific sub-population or reporting non-psychosocial interventions were excluded. Data was extracted from articles by a standard form. Meta-analysis was conducted to obtain a summary measure of the effectiveness of the interventions in reducing perinatal depressive symptoms. The theoretical underpinnings and implementation processes of the interventions were also characterised. Findings: A total of 6,857 articles were identified in the initial database searching, of which, 26 studies were eligible for data analysis, representing a sample size of 4,673. Meta-analysis indicated that psychosocial interventions in China significantly reduced perinatal depressive symptoms (standard difference in means 0·81, 95% confidence intervals -1·03 to -0·58, P<0·001). However, the overall evidence presented substantial heterogeneity (I 2 =91·12%). Most interventions were implemented in hospitals in urban areas by non-specialist health care providers. Few studies reported details of implementation procedures or scale-up strategies. Interpretation: Current psychosocial interventions in China are somewhat effective in reducing perinatal depressive symptoms. High quality randomized controlled trials on scale-up interventions are required, especially in rural areas. Funding Statement: This study was supported by the Chinese Nursing Association (ZHKY201809). Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: This review was registered with PROSPERO (CRD42018115934).

Knowledge and attitudes towards epilepsy among nonmedical health workers in rural Bolivia: Results after a long-term activity in the Chaco region

IntroductionEpilepsy represents a major global healthcare issue, particularly in low- and middle-income countries (LMIC), where nonmedical health workers play a key role in providing care to people with epilepsy (PWE). Over the last 20 years, many projects have been carried out by our group in the Chaco region, Plurinational State of Bolivia, with the aim of enhancing knowledge about epilepsy. However, the level of knowledge of epilepsy that nonmedical health workers have reached has never been assessed until now.The main objective of our study was to assess the level of knowledge, attitudes, and practices (KAP) towards epilepsy among nonmedical health staff of the rural communities of the Chaco region in Bolivia. MethodsThe study was conducted in three departments of Bolivia. The nonmedical health personnel were invited to participate in a training program. They answered a validated questionnaire to evaluate their knowledge and attitudes towards epilepsy before and after the courses. ResultsOne hundred nineteen subjects [42 men (36.2%); mean age 29.3 ± 1.1 years] were interviewed among community health workers and nurses before the courses, demonstrating a very good level of knowledge regarding epilepsy and its causes. Only 55 health workers participated in the second training module, and their answer did not significantly differ from the baseline. ConclusionOur study confirms the usefulness of continuous educational campaigns, especially directed to nonspecialist healthcare providers of rural communities of LMIC, as they may be the only persons responsible for providing healthcare to PWE in that setting. Moreover, the importance of the baseline assessment of KAP was highlighted in order to adapt the educational campaigns to the baseline level of knowledge found.

Expanding Treatment Access for Chronic Hepatitis C with Task-shifting in the Era of Direct-acting Antivirals.

In the United States, the fight to eradicate hepatitis C virus (HCV) infection has been ongoing for many years, but the results have been less than ideal. Historically, patients with chronic hepatitis C (CHC) were treated with interferon-based regimens, which were associated with frequent adverse effects, suboptimal response rates, and long durations of treatment – of up to 48 weeks. Expertise from specialist-physicians, such as hepatologists and gastroenterologists, was needed to closely follow patients on these medications so as to monitor laboratory values and manage adverse effects. However, the emergence of direct-acting antiviral (DAA) agents against HCV infection have heralded outstanding progress in terms of safety, tolerability, lack of adverse effects, efficacy, and truncated duration of therapy – 12 weeks or less – thereby making the need for close monitoring by specialist-physicians obsolete. With the recent approval of DAA agents by the Food and Drug Administration, the treatment model for CHC no longer relies on the limited number of specialist-physicians, which represented a major barrier to treatment access in the past, especially in underserved areas of the United States. We propose and share our experiences in adapting a task-shifting treatment model, one that utilizes a relatively larger pool of non-specialist healthcare providers, such as nursing staff (medical assistants, vocational licensed nurses, registered nurses, etc.) and advanced practice providers (nurse practitioners and physician assistants), to perform a variety of important clinical functions in an effort to make DAA-based antiviral therapy widely available against HCV infection. Most recently, task-shifting was implemented by the United States and World Health Organization in the fight against the human immunodeficiency virus and showed encouraging results. Based on our experiences in implementing this model at our outreach clinics, the majority of HCV-infected patients treated with DAA agents can be easily monitored by non-specialist healthcare providers and physician extenders. Task-shifting can effectively address one of the major rate-limiting factors in expanding treatment access for HCV infection.

Psychiatric morbidity in the community: A population based-study from Kerala.

Background:Estimates of psychiatric morbidity in the community will help service development. Participation of trained nonspecialist health-care providers will facilitate scaling up of services in resource-limited settings.Aims:This study aimed to estimate the prevalence of priority mental health problems in populations served by the District Mental Health Program (DMHP).Settings and Design:This is a population-based cross-sectional survey.Materials and Methods:We did stratified cluster sampling of households in five districts of Kerala. Trained Accredited Social Health Activists (ASHAs) identified people who had symptoms suggestive of schizophrenia or bipolar disorder. Clinicians evaluated the information collected by the ASHAs and designated individuals as probable cases of psychosis or noncases. Screening instruments such as General Health Questionnaire-12, CAGE questionnaire, and Everyday Abilities Scale for India were used for identifying common mental disorders (CMDs), clinically significant alcohol-related problems, and functional impairment.Results:We found 12.43% of the adult population affected by mental health conditions. We found CMD as most common with a prevalence of 9%. The prevalence of psychosis was 0.71%, clinically significant alcohol-related problems was 1.46%, and dementia and other cognitive impairments was 1.26%. We found informant-based case finding to be useful in the identification of psychosis.Conclusions:Mental health problems are common. Nonspecialist health-care providers can be trained to identify psychiatric morbidity in the community. Their participation will help in narrowing the treatment gap. Embedding operational research to DMHP will make scaling up more efficient.

Growing concern about maternal mental health disorders

Received: April 20, 2015; Accepted: May 19, 2015; Published: May 22, 2015 Globally one in three women of developing countries and one in ten women of developed countries are suffering from some form of mental health problem either during pregnancy or after childbirth [1]. Depression and anxiety are the major mental health disorders seen among the mothers and numbers of suicides among severe cases are increasing day by day. Mental health problem among the mother adversely affects the child’s growth and development as well. Maternal mental health disorders are preventable and also easily treatable if identified early. And, most of these problems can be easily managed even by non-specialist healthcare providers who are properly trained. In order to achieve the Millennium Development Goal (MDG) 5 of improving maternal health, efforts should include measures for prevention and management of maternal mental health disorders [2].

Spanish consensus on premature menopause

IntroductionWhile we recognise that the term premature menopause is more accepted by most non-specialist health care providers and by the general population, ‘primary ovarian insufficiency’ (POI) is currently considered the most apposite term to explain the loss of ovarian function, because it better explains the variability of the clinical picture, does not specify definitive failure, and highlights the specific ovarian source. Its pathogenesis involves a congenital reduction in the number of primordial follicles, poor follicle recruitment, or accelerated follicular apoptosis. However, its cause is unknown in most cases. AimThis guide analyses the factors associated with the diagnosis and treatment of POI and provides recommendations on the most appropriate diagnostic and therapeutic measures for women under 40 years of age who experience POI. MethodologyA panel of experts from various Spanish scientific societies related to POI (Spanish Menopause Society, Spanish Fertility Society, and Spanish Contraception Society) met to reach a consensus on these issues. ResultsHormonal therapy (HT) is considered the treatment of choice to alleviate the symptoms of hypoestrogenism and to prevent long-term consequences. We suggest that HT should be continued until at least age 51, the average age at natural menopause. The best treatment to achieve pregnancy is oocyte/embryo donation. If a patient is to undergo treatment that will reduce her fertility, she should be informed of this issue and the available techniques to preserve ovarian function, mainly vitrification of oocytes.

Management of female genital trauma

The management of female genital trauma is complex and should be performed by a well-trained team of health care professionals. It is important to remember that many female genital injuries will cause not just physical injury, but also significant psychological and emotional distress that may lead on to future physical dysfunction. The approach of any health care professional in the immediate diagnosis and management of females with a genital injury must be aimed at getting the best and most appropriate care to the patient as soon as possible. It is also important to remember that many of these injuries are the result of crimes and careful documentation is required so as not to remove or invalidate evidence that may later be required by the courts. This article is aimed at non-specialist healthcare providers who may find themselves faced with a female genital trauma patient. It will cover the range of injuries and conditions that should be expected and describes the treatment that should be given for the best possible physical and psychological outcomes. At all times it should be remembered that the patient should be assessed and resuscitated in accordance with recognised ATLS protocols.

FEMALE STERILIZATION: Evidence

The literature review herein reveals substantial information regarding the safety, efficacy, short-term complications, long-term complications, and noncontraceptive benefits of sterilization. This information should be helpful for providers and potential sterilization candidates. The review also reveals areas where the data are unclear. Points to keep in mind during counseling include the following: The vast majority of women are satisfied with the decision to undergo sterilization. The fact that regret occurs underscores the importance of counseling and adequate individual deliberation before the procedure. In addition to the difficulty and expense associated with sterilization reversal, the woman should thoroughly understand the permanence of the procedure. Although failure is a rare event, it can occur many years after the procedure. Although evidence suggests that hysterectomy rates are higher in sterilized women aged less than 30 to 35 years, it is unlikely that there is a plausible biologic effect of sterilization on hysterectomy risk. An association between tubal sterilization and menstrual cycle changes does not seem valid for changes noted up to 2 years after the procedure. Data are unclear and inconsistent among studies observing women more than 2 years after the procedure. Evidence consistently shows that sterilization is associated with a reduced incidence of ovarian cancer and pelvic inflammatory diseases. Most studies show no effect or improvement of sexual satisfaction after sterilization. Complications during and postprocedure are rare. Sterilization provides no protection against the acquisition of sexually transmitted disease. Patients and their physicians should recognize that sterilized women may need more targeted preventive efforts for health screening and to reduce high-risk behavior than women who use other contraceptive methods. The surgeon's experience and the woman's preferences should govern the ultimate decision regarding the approach and occlusion method. Level II-2 evidence indicates comparable safety between interval laparoscopy and minilaparotomy. Data consistently show that in experienced trained hands, tubal sterilization is safe and highly effective regardless of the approach or occlusive method. Attention to the subtleties of technique seems to be most important in ensuring procedure safety and efficacy. Reanalysis of the CREST data shows that the cumulative failure rate of bipolar coagulation is comparable with the failure rate of unipolar coagulation if a substantial length of tube is adequately coagulated. The data discussed herein can be used to guide management decisions that may increase accessibility and reduce cost of the procedure. Low-resource settings and office settings have maintained an excellent safety record for this procedure through performance of sterilization under local anesthesia. The use of local anesthesia enables a change in procedure location from an inpatient operating room to a free-standing surgical clinic or adequately equipped office. Local anesthesia, with or without preoperative medication, is an excellent option associated with a lower complication risk, reduced cost, and shorter, easier recovery. The surgeon should have specific training in the effective use of local anesthetics, preoperative medications, and management of rare complications in low-resource settings. Little additional research is needed regarding the safety and efficacy of standard sterilization approaches and occlusion methods. There is a need for continued development of nonsurgical methods of sterilization, microlaparoscopic approaches performed in the office setting, and the feasibility and acceptance of service provision by nonspecialist health care providers. The evidence indicates that female sterilization can be performed safely in a variety of resource settings ranging from rural sterilization camps in developing countries to high-tech, resource-rich operating rooms in developed c