Services In Low-resource Settings Research Articles

Design and implementation of an m-health data model for improving health information access for reproductive and child health services in low resource settings using a participatory action research approach

BackgroundInformation and Communication Technologies (ICTs) have been utilised globally for advancing social and economic development. As information becomes key to enlightening development initiatives, the role of mobile technology-based ICT services is becoming more significant. The aim of this study was to design and implement a mHealth data model with an intention of improving mothers’ knowledge of Reproductive and Child Health (RCH) services in rural environments and to remind mothers who do not have access to mobile phones to attend antenatal care.MethodsThe methodology adopted in this research was participatory action research. A phased approach was utilised to answer the research question. The phases were: diagnosis of the problem, action planning, action taking, evaluation and reflection. The study was conducted in Chamwino district of Dodoma region, Tanzania. Reproductive and Child Health sections of Buigiri dispensary and Chamwino health centre were purposively selected. Data were collected through key informant interviews, document review, focus group discussion and observation. Content analysis methods were utilised during analysis. Consequently, the data model was designed, implemented and evaluated.ResultsChallenges of information dissemination in low resource settings noted in this study are: mobile phone ownership and access of mothers, vertical coordination of health services and low staffing levels of health workers. Mothers who do not own mobile phones can leverage phone ownership of community leaders, TBAs, CHWs and relatives. This in turn facilitates communication of health messages to mothers.ConclusionsAlthough this study was conducted in a low resource setting, mobile network coverage was good and thus SMS technology could be used. Research should be conducted on how to disseminate similar information in remote areas without mobile coverage.

Demand and capacity to integrate pelvic organ prolapse and genital fistula services in low-resource settings

Introduction and hypothesisThere is a need for expanded access to safe surgical care in low- and middle-income countries (LMICs) as illustrated by the report of the 2015 Lancet Commission on Global Surgery. Packages of closely-related surgical procedures may create platforms of capacity that maximize impact in LMIC. Pelvic organ prolapse (POP) and genital fistula care provide an example. Although POP affects many more women in LMICs than fistula, donor support for fistula treatment in LMICs has been underway for decades, whereas treatment for POP is usually limited to hysterectomy-based surgical treatment, occurring with little to no donor support. This capacity-building discrepancy has resulted in POP care that is often non-adherent to international standards and in non-integration of POP and fistula services, despite clear areas of similarity and overlap. The objective of this study was to assess the feasibility and potential value of integrating POP services at fistula centers.MethodsFistula repair sites supported by the Fistula Care Plus project were surveyed on current demand for and capacity to provide POP, in addition to perceptions about integrating POP and fistula repair services.ResultsRespondents from 26 hospitals in sub-Saharan Africa and South Asia completed the survey. Most fistula centers (92%) reported demand for POP services, but many cannot meet this demand. Responses indicated a wide variation in assessment and grading practices for POP; approaches to lower urinary tract symptom evaluation; and surgical skills with regard to compartment-based POP, and urinary and rectal incontinence. Fistula surgeons identified integration synergies but also potential conflicts.ConclusionsIntegration of genital fistula and POP services may enhance the quality of POP care while increasing the sustainability of fistula care.

Neurosurgical Care: Availability and Access in Low-Income and Middle-Income Countries.

An estimated 5 billion people worldwide lack access to basic surgical care. In particular, the vast majority of low-income and middle-income countries (LMICs) currently struggle to provide adequate neurosurgical services. Significant barriers exist, including limited access to trained medical, nursing, and allied health staff; lack of equipment; and availability of services at reasonable distance and at reasonable cost to patients. An accurate assessment of current neurosurgical capacity in LIMCs is an essential first step in tackling this deficit. To quantify the neurosurgical operational capacity and assess access to neurosurgical services in LMICs, by taking into account the location of workforce and services. A total of 141 LMICs were contacted and asked to report the number of currently practicing neurosurgeons, access to computed tomographic and magnetic resonance imaging, and availability of neurosurgical equipment (microscope, endoscope, bipolar diathermy, high-speed neurosurgical drill). A proposed World Federation of Neurosurgeons classification was used to stratify cities based on the level of neurosurgical care that could be provided. The data were geocoded and analyzed in Redivis (Redivis Inc.) to assess the percentage of the population covered within a 2-hour travel time of a city offering differing levels of neurosurgical care. 68 countries provided complete data (response rate, 48.2%). Eleven countries reported having no practicing neurosurgeons. The average percentage of the population with access to neurosurgical services within a 2-hour window is 25.26% in sub-Saharan Africa, 62.3% in Latin America and the Caribbean, 29.64% in East Asia and the Pacific, 52.83% in South Asia, 79.65% in the Middle East and North Africa, and 93.3% in Eastern Europe and Central Asia. There are several challenges to the provision of adequate neurosurgical services in low-resource settings. This study used mapping techniques to determine the current global neurosurgical workforce capacity and distribution. We have used our findings to identify areas for improvement. These include increasing and improving neurosurgical training programs worldwide, recruiting students and young physicians into the field, and retaining existing neurosurgeons within their home countries.

The development and implementation of a layperson trauma first responder course in La Paz, Bolivia: A pilot study

BackgroundNinety percent of nearly five million annual global injury deaths occur in low- and middle-income countries (LMICs), where prehospital care systems are frequently rudimentary or nonexistent. The World Health Organization considers layperson first-responders as essential for emergency medical services in low-resource settings lacking more formalized systems. This study sought to develop and implement a layperson trauma first responder course (TFRC) in Bolivia. Materials and methodsIn March and April 2013 nine sessions of the eight-hour TFRC were held in La Paz, Bolivia. The course charged a nominal fee, and was led by an American surgeon and medical student. The TFRC built upon existing models with local stakeholder input, and included both didactic and practical components. Participants completed a baseline survey, and pre and posttests. The primary outcome was test performance, with secondary outcomes including demographic sub-group test score analyses and exam question validation. Data were assessed using nonparametric and psychometric methods ResultsOne hundred fifty-nine individuals met study inclusion criteria. Participant median age was 28 (IQR 24, 36), 49.1% were male, 59.1% worked in a medical field, most had secondary (35.2%) or university (56.0%) level educations, and 67.3% had prior first aid training. Median test scores improved after course completion (48% vs. 76%, p <0.001), along with skill confidence (4 vs. 4.5, p <0.001). Most questions had appropriate item difficulty indices, point bi-serial correlation coefficients, and positive Pretest Posttest Difference Indices. Cronbach alpha coefficients for pre and posttest scores were 0.72 and 0.78, respectively. ConclusionsThis study presents data from the first offering of an original TFRC for laypeople in Bolivia. Increased participant knowledge and skill confidence after course completion, and acceptable overall psychometric test properties, indicate this model is valid and effective. Future aims include TFRC revision, and enrollment of more layperson first responders to increase population-level impacts.

Bridging the gap in mental health and psychosocial services in low resource settings

Bridging the gap in mental health and psychosocial services in low resource settings

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

BackgroundIn low resource settings, short, valid and reliable instruments with good high sensitivity and specificity are essential for the screening of depression in antenatal care. A review of published evidence on screening instruments for depression for use in antenatal services in low resource settings was conducted. The aim of this review was to appraise the best available evidence on screening instruments suitable for detecting depression in antenatal care in low resource settings.MethodsSearching, selection, quality assessment, and data abstraction was done by two reviewers. ScienceDirect, CINAHL, MEDLINE, PubMed, SABINET and PsychARTICLES databases were searched using relevant search terms. Retrieved studies were evaluated for relevancy (whether psychometric data were reported) and quality. Data were synthesised and sensitivity and specificity of instruments were pooled using forest plots.ResultsEleven articles were included in the review. The methodological quality ranged from adequate to excellent. The review found 7 tools with varying levels of accuracy, sensitivity and specificity, including the Edinburgh Postnatal Depression Scale, Beck Depression Index, Centre for Epidemiologic Studies Depression Scale 20, Hamilton Rating Scale for Depression, Hopkins Symptoms Checklist-25, Kessler Psychological Distress Scale and Self-Reporting Questionnaire. The Edinburgh Postnatal Depression Scale was most common and had the highest level of accuracy (AUC = .965) and sensitivity.ConclusionThis review suggests that the Edinburgh Postnatal Depression Scale can be a suitable instrument of preference for screening antenatal depression in low resource settings because of the reported level of accuracy, sensitivity and specificity.Prospero registrationCRD42015020316.

Sustaining an Equitable Heath System: Need for Evidence Informed Decision Making

Provision of universal health coverage has drawn attention across the globe. Attaining equity in service provision while sustaining the health system has become the major challenge. As limited resources become a barrier to achieve both at the same time, short term measures dominate policy cycles based on options and interests of individuals and groups than hard evidence. Taking Sri Lankan health system as an example this paper discusses the importance of evidence based decisions to achieve both equity and sustainability of services in low resource settings.

Use of short messaging services to assess depressive symptoms among refugees in South Africa: Implications for social services providing mental health care in resource-poor settings

Introduction Few studies in developing nations have assessed the use of short messaging services (SMS) to identify psychological challenges in refugee populations. This study aimed to assess the feasibility of SMS-based methods to screen for depression risk among refugees in South Africa attending mental health services, and to compare its reliability and acceptability with face-to-face consultation. Methods Of the 153 refugees enrolled at baseline, 135 were available for follow-up assessments in our cohort study. Depression symptomatology was assessed using the 16-item Quick Inventory of Depressive Symptomatology (QIDS) instrument. Results Nearly everyone possessed a mobile phone and utilized SMS. Furthermore, low incomplete item response in QIDS and high perceived ease of interacting via SMS with service providers supported the feasibility of this method. There was a fair level of reliability between face-to-face and SMS-based screening methods, but no significant difference in preference rating between the two methods. Conclusion Despite potential implementation barriers (network delay/phone theft), depression screening using SMS may be viable for refugee mental health services in low-resource settings.

Mental health service provision in low and middle-income countries: recent developments.

The study discusses key issues and concepts of how to provide basic mental health services for people with mental disorders in low and middle-income countries (LAMICs). In the last years a considerable gap between mental healthcare needs and available services in LAMICs has been documented. The transformation of hospital-based to community-based mental health and the building of accessible services in low-resource settings require mental health training of primary care providers, task-sharing/task-shifting models, involvement of families and peers and basic models of community rehabilitation. Several international initiatives have been set up to increase the evidence base and test the feasibility, acceptability, and effectiveness of these approaches which are not new but which have been implemented in only a small amount of LAMICs. A combination of interventions on different levels (governance, legislation, providers, and community) is necessary. It remains to be shown how the recent global mental health movement, beyond increasing international financial resources, will be helpful in finding locally and culturally sensitive solutions to reduce the mental health gap in LAMICs. Although concepts of a well designed mix of services are available, solutions to reduce implementation barriers must be local, and implementation strategies may vary considerably and still lack a sufficient evidence base.

Cardiac rehabilitation delivery model for low-resource settings

ObjectiveCardiovascular disease is a global epidemic, which is largely preventable. Cardiac rehabilitation (CR) is demonstrated to be cost-effective and efficacious in high-income countries. CR could represent an important approach to mitigate the epidemic of cardiovascular disease in lower-resource settings. The purpose of this consensus statement was to review low-cost approaches to delivering the core components of CR, to propose a testable model of CR which could feasibly be delivered in middle-income countries.MethodsA literature review regarding delivery of each core CR component, namely: (1) lifestyle risk factor management (ie, physical activity, diet, tobacco and mental health), (2) medical risk factor management (eg, lipid control, blood pressure control), (3) education for self-management and (4) return to work, in low-resource settings was undertaken. Recommendations were developed based on identified articles, using a modified GRADE approach where evidence in a low-resource setting was available, or consensus where evidence was not.ResultsAvailable data on cost of CR delivery in low-resource settings suggests it is not feasible to deliver CR in low-resource settings as is delivered in high-resource ones. Strategies which can be implemented to deliver all of the core CR components in low-resource settings were summarised in practice recommendations, and approaches to patient assessment proffered. It is suggested that CR be adapted by delivery by non-physician healthcare workers, in non-clinical settings.ConclusionsAdvocacy to achieve political commitment for broad delivery of adapted CR services in low-resource settings is needed.

Opportunistic Breast Cancer Education and Screening in Rural Honduras

PurposeIn Honduras, the breast cancer burden is high, and access to women’s health services is low. This project tested the connection of community-based breast cancer detection with clinical diagnosis and treatment in a tightly linked and quickly facilitated format.MethodsThe Norris Cotton Cancer Center at Dartmouth College partnered with the Honduran cancer hospital La Liga Contra el Cancer to expand a cervical cancer screening program, which included self-breast exam (SBE) education and clinical breast exams (CBEs), to assess patient attitudes about and uptake of breast cancer education and screening services. The cervical cancer screening event was held in Honduras in 2013; 476 women from 31 villages attended.ResultsHalf of the women attending elected to receive a CBE; most had concerns about lactation. Clinicians referred 12 women with abnormal CBEs to La Liga Contra el Cancer for additional evaluation at no cost. All referred patients were compliant with the recommendation and received follow-up care. One abnormal follow-up mammogram/ultrasound result was negative on biopsy. One woman with an aggressive phyllodes tumor had a mastectomy within 60 days. Multimodal education about breast cancer screening maximized delivery of women’s health services in a low-tech rural setting.ConclusionThe addition of opportunistic breast cancer education and screening to a cervical cancer screening event resulted in high uptake of services at low additional cost to program sponsors. Such novel strategies to maximize delivery of women’s health services in low-resource settings, where there is no access to mammography, may result in earlier detection of breast cancer. Close follow-up of positive results with referral to appropriate treatment is essential.

Emory Global Surgery Program: Learning to Serve the Underserved Well

Over the past 25 years, there has been a surge in interest andactivity surrounding surgery in public health, the globalsurgical workforce, and the availability and quality ofsurgical services in low-resource settings. Significant researchand encouraging progress has been made on numerousfronts, from studies quantifying various aspects of theburden of surgical disease to innovative projects buildingand strengthening surgical capacity.

Mental health screenings for couples at churches in Nigeria: a strategy for enhancing community-based maternal mental health services in low-resource settings.

The burden of perinatal mental disorders among women in low- and middle-income countries is substantial. The current integration of mental health into maternal, neonatal and child health service platforms is limited, despite global calls to prioritize such service integration. The study by Iheanacho and colleagues (2014) entitled "Integrating mental health screening into routine community maternal and child health activity: experience from a prevention of mother-to-child HIV transmission (PMTCT) trial in Nigeria" provides promising evidence about the feasibility of a church-based strategy for screening pregnant women and their partners for mental health problems through a PMTCT program.

Assessing the Quality of Teleconsultations in a Store-And-Forward Telemedicine Network - Long-Term Monitoring Taking into Account Differences between Cases.

We have previously proposed a method for assessing the quality of individual teleconsultation cases; this paper proposes an additional step to allow the long-term monitoring of quality. The basic scenario is a teleconsultation system (aka an e-referral system or a tele-expertise system) where the referrer posts a question about a clinical case, the question is relayed to an appropriate expert, and the chosen expert provides an answer. The people running this system want assurances that it is stable, i.e., they want routine quality assurance information about the “output” from the “process.” This requires two things. It needs a method of assessing the quality of individual patient consultations. And it needs a method for taking into account differences between patients, so that these quality assessments can be compared longitudinally. Building on the previously proposed methodology, the present paper proposes two techniques for measuring the difficulty posed by a particular teleconsultation. The first is an indirect method, similar to a willingness to pay economic estimation. The second is a direct method. Using these two methods with real data from a telemedicine network showed that the first method was feasible, but did not produce useful results in a pilot trial. The second method, while more laborious, was also feasible and did produce useful results. Thus, when output quality is measured, an allowance can be made for the characteristics of the case submitted. This means that fluctuations in output quality can be attributed to variations in the process (network) or to variations in the raw materials (queries submitted to the network). Long-term quality assurance should assist those providing telemedicine services in low-resource settings to ensure that the services are operated effectively and efficiently, despite the constraints and complexities of the environment.

Maternal near-miss and mortality in Sayaboury Province, Lao PDR.

BackgroundMaternal near-miss (MNM) incidence is the indicator reflecting maternal healthcare services. This study aimed to determine the burden of maternal near-miss and maternal deaths in Sayaboury Province, Lao PDR.MethodsA descriptive study was done in a cohort of 1215 pregnant women, who had their last normal menstrual period (LMP) between 1 August and 31 December, 2010. WHO criteria for MNM were used to identify near-miss cases and maternal deaths during February – November 2011. Data of maternal characteristics, MNM, and maternal deaths were prospectively collected by primary health care workers in the villages under supervision of health staff in local health centers and by the head nurses of the gynecology - obstetric wards in the studied hospitals. Frequencies with 95% confidence intervals (CIs) were used to describe maternal near-misses and maternal deaths.ResultsOverall, 92.5% of the 1215 pregnancies were delivered, 7.5% were aborted. Eleven women were identified as near-miss cases, giving a maternal near miss (MNM) ratio of 9.8 (95% CI: 4.9 -17.5)/1,000 live births. With two maternal deaths, the maternal mortality ratio (MMR) was 178 (95% CI: 50–650)/100,000 live births. Together, these constituted 13 cases of severe maternal outcome (SMO) and given the SMO ratio of 11.6 (95% CI: 6.2 - 19.8)/1,000 live births.ConclusionThe study shows a surprisingly low MNM ratio and MMR in Sayaboury Province, Lao PDR. Generalization of the results is limited by problems in applying standard criteria for the identification of near-misses in the communities and local hospitals. However, the findings are considered to have important implications for the improvement of maternal health services in low resource settings, e.g. to obtain valid and reliable maternal near miss and maternal deaths for the whole country.

Implementation of best practice for dyspepsia management in an outpatient hospital setting in Kenya

Background Dyspepsia is a range of symptoms referable to the upper gastrointestinal tract. These include heartburn, acid regurgitation, abdominal bloating, excessive belching, nausea, recurrent vomiting, unexplained weight loss and anaemia. Dyspepsia management is a challenge for clinicians as underlying pathology varies from life threatening to benign. It is vital for patient well-being that individuals with alarm signal symptoms are referred for the kind of treatment their life-threatening symptoms require. To facilitate efficient use of scarce societal resources, which is particularly important in low-resource settings like the one in which this project was undertaken, patients without alarm signals need to be given advice on how to manage their discomfort, not expensive screening tests or treatment. Objectives The goal of this project was to improve local practice in assessment and management of dyspepsia in an outpatient hospital setting in Kenya. Search strategy The project used the Joanna Briggs Institute's Practical Application of Clinical Evidence System and Getting Research into Practice audit tool for promoting change in health practice. A baseline audit was conducted followed by an education strategy targeted at clinicians and follow-up audit. Conclusion The baseline audit revealed large gaps between practice and best practice in all but one of seven audit criteria, namely documentation of acid suppression therapy for patients with alarm symptoms. Resource limitations including lack of equipment (e.g. endoscopy) and insufficient staff to meet demand for services as well as clinicians lacking knowledge about best practice emerged as the primary factors behind the best practice gaps. Poor medical record keeping may explain why the compliance with best practice emerged as so poor for the majority of the audit criteria in the baseline audit. In the follow-up audit, five of the seven audit criteria showed improved compliance with best practice. However, with the exception of one, improvement was off a very low base so there remained much room for improvement. For example, in the second audit, the patient medical records audited showed evidence of only 29% of patients being provided with education about lifestyle modifications that may alleviate dyspepsia symptoms and in only 47% of the patient records is there a note about presence or absence of alarm signals (up from 30% at baseline). Conclusions The project presents another example of how audit may be used to promote best practice in healthcare. Yet it also shows the vastness of the challenge confronting champions working to promote evidence-informed health practice and equity in access to health services in low-resource settings and the need for not only clinician-focused, capacity-building initiatives but also strategies to mobilise resources for health facilitates.

Effectiveness of cryotherapy for histologically confirmed cervical intraepithelial neoplasia grades 1 and 2 in an Indian setting

ObjectiveTo describe the effectiveness of cryotherapy for treating women who were histologically confirmed to have cervical intraepithelial neoplasia (CIN) in India. MethodsData were analyzed retrospectively from screening projects that collected data from January 2001 to May 2008 in Trivandrum, India. Women with CIN were appropriately treated with cryotherapy by a trained nurse or physician and followed up for cure, adverse events, and complications. Cure was defined as absence of CIN during any follow-up visit at least 1 year after treatment. ResultsAmong 236 women identified with CIN and appropriately treated with cryotherapy, 173 (81.6%) were followed up (158 CIN 1 and 15 CIN 2 cases). The percentage cure for CIN 1 and 2 lesions was 93.0% and 86.7% respectively. An odds ratio of 0.2 (95% confidence interval, 0.0–0.9) was observed for treatment received more than 2 months after screening as compared with treatment received within 2 months. Complications were observed in 1.2% of treated women and adverse events (discharge and mild pain) in 26.6%. ConclusionThe study affirms that trained mid-level providers can appropriately perform cryotherapy in primary healthcare services and that expanding such services in low-resource settings would increase the availability and accessibility of precancer treatment.

The Pediatric Autopsy in Africa

Within the continent of Africa few countries have been able to practice pathology at the levels present in Europe and the Americas, and pediatric pathology does not exist as a stand-alone specialty. The author was invited by a colleague from Harvard Medical School, Boston, Massachusetts, to join a group of North American pathologists in presenting a course on the Contribution of Anatomic Pathology for advancing the health of women and children in Africa. The course was held in Ethiopia in June 2011, to review the current state of pediatric pathology in Africa and to provide resources/teaching for improving pediatric pathology services in low-resource settings. To provide a succinct description of applicable autopsy techniques and the interpretation of gross, microscopic, and ancillary findings with respect to Africa's need to enhance the health of women and children. The author makes suggestions for obviating possible problems in anticipation of increased demands by national authorities and of public expectations of pathologists who usually have had only general training. This article is based upon the author's personal experience of practicing pathology in Africa for the past 51 years, which has included visiting pathology laboratories in 9 African countries and interacting with colleagues in 18 additional African countries. The contents of this article are derived from personal observations, recent publications, and information gleaned from Internet sources. Even without specific training in pediatric pathology, it is possible for pediatric autopsies to be undertaken in Africa and other resource-poor settings, in a manner that facilitates sound decision making for improving the health of women and children.

Replicating PEPFAR’s Success: How Interventions Shown To Be Effective Abroad Can Be Applied To The AIDS Epidemic In The US

The President's Emergency Plan for AIDS Relief (PEPFAR), which began in 2003, initially responded to the global AIDS epidemic by applying lessons learned in treating the disease in the United States to addressing the emergency abroad. As the program expanded, it evolved to support interventions increasingly tailored to local needs in countries receiving PEPFAR assistance. This global experience has created a knowledge base of how to provide HIV/AIDS prevention, care, and treatment services in low-resource settings. It underscored the importance of treatment adherence, family-centered care, and integration of HIV into broader health care delivery systems. Applying these lessons can help US policy makers address existing gaps in HIV care in the United States, where the availability of HIV treatment has at times masked the continued need for testing, early diagnosis, targeted prevention for key populations, and a solid array of social services for people living with HIV/AIDS and their families. This article identifies PEPFAR practices that merit further exploration for adoption in the United States, including strategies to increase adherence to drug treatment regimens and to ensure that HIV services are broadly integrated with other aspects of health care.

Assessing skilled birth attendants and emergency obstetric care in rural Tanzania: the inadequacy of using global standards and indicators to measure local realities

Current efforts to reduce maternal mortality and morbidity in low-resource settings often depend on global standards and indicators to assess obstetric care, particularly skilled birth attendants and emergency obstetric care. This paper describes challenges in using these standards to assess obstetric services in the Kilombero Valley of Tanzania. A health facility survey and extensive participant observation showed existing services to be complicated and fluid, involving a wide array of skills, resources, and improvisations. Attempts to measure these services against established standards and indicators were not successful. Some aspects of care were over-valued while others were under-valued, with significant neglect of context and quality. This paper discusses the implications of these findings for ongoing maternal health care efforts in unique and complex settings, questioning the current reliance on generic (and often obscure) archetypes of obstetric care in policy and programming. It suggests that current indicators may be insufficient to assess services in low-resource settings, but not that these settings should settle for lower standards of care. In addition to global benchmarks, assessment approaches that emphasize quality of care and recognize available resources might better account for local realities, leading to more effective, more sustainable service delivery.