We conducted a needs assessment to identify knowledge gaps in the management of tropical diseases by Canadian emergency physicians and identify available, related continuing medical education (CME) ...resources.
A literature review was conducted to summarize challenges in the management of commonly encountered tropical diseases. An anonymous online survey was administered to Canadian emergency physicians using the Canadian Association of Emergency Physicians survey deployment service in July and August 2012. The survey identified self-reported gaps in knowledge and assessed knowledge using case-based vignettes. A list of CME resources was generated from a review of major academic emergency medicine journals, online cases, and conference topics from emergency medicine associations during 2010-2011. Two independent reviewers assessed the relevance of the resources; differences were resolved by consensus.
From 635 citations, 47 articles were selected for full review; the majority (66%) were retrospective chart reviews, few (10.6%) had an emergency medicine focus, and fewer still were Canadian (8.5%). In total, 1,128 surveys were distributed, and 296 (27%) participants were included in the study. Most respondents reported "no" (52.4%) or "some" (45.9%) training in tropical medicine. Most (69.9%) rated their comfort in managing patients with tropical diseases as "low." Few (11.1%) respondents reported a tropical disease being misdiagnosed or mismanaged; 44.1% indicated malaria. The perceived need for further training was high (76.7%). Conference workshops were the most highly requested CME modality, followed by case studies and podcasts. Correct answers to case vignettes ranged from 30.7 to 58.4%. Although 2,038 CME titles were extracted from extensive searches, only 6 were deemed relevant.
Most Canadian emergency physicians have had minimal training in tropical diseases, reported a low comfort level in their management, and identified a high need for CME opportunities, which are lacking.
Despite availability of effective treatment, tuberculosis (TB) remains an important cause of morbidity and mortality globally, with low- and middle-income countries most affected. In many such ...settings, including Malawi, the high burden of disease and severe shortage of skilled healthcare workers has led to task-shifting of outpatient TB care to lay health workers (LHWs). LHWs improve access to healthcare and some outcomes, including TB completion rates, but lack of training and supervision limit their impact. The goals of this study are to improve TB care provided by LHWs in Malawi by refining, implementing, and evaluating a knowledge translation strategy designed to address a recognized gap in LHWs' TB and job-specific knowledge and, through this, to improve patient outcomes.
We are employing a mixed-methods design that includes a pragmatic cluster randomized controlled trial and a process evaluation using qualitative methods. Trial participants will include all health centers providing TB care in four districts in the South East Zone of Malawi. The intervention employs educational outreach, a point-of-care reminder tool, and a peer support network. The primary outcome is proportion of treatment successes, defined as the total of TB patients cured or completing treatment, with outcomes taken from Ministry of Health treatment records. With an alpha of 0.05, power of 0.80, a baseline treatment success of 0.80, intraclass correlation coefficient of 0.1 based on our pilot study, and an estimated 100 clusters (health centers providing TB care), a minimum of 6 patients per cluster is required to detect a clinically significant 0.10 increase in the proportion of treatment successes. Our process evaluation will include interviews with LHWs and patients, and a document analysis of LHW training logs, quarterly peer trainer meetings, and mentorship meeting notes. An estimated 10-15 LHWs and 10-15 patients will be required to reach saturation in each of 2 planned interview periods, for a total of 40-60 interview participants.
This study will directly inform the efforts of knowledge users within TB care and, through extension of the approach, other areas of care provided by LHWs in Malawi and other low- and middle-income countries.
ClinicalTrials.gov NCT02533089 . Registered 20 August 2015. Protocol Date/Version 29 May 2016/Version 2.
Despite recent improvements, uptake and retention of mothers and infants in prevention of mother-to-child transmission (PMTCT) services remain well below target levels in many low- and middle-income ...countries (LMICs). Identification of effective interventions to support uptake and retention is the first step towards improvement. We aim to complete a systematic review and meta-analysis to evaluate the effectiveness of interventions at the patient, provider or health system level in improving uptake and retention of HIV-infected mothers and their infants in PMTCT services in LMICs.
We will include studies comparing usual care or no intervention to any type of intervention to improve uptake and retention of HIV-infected pregnant or breastfeeding women and their children from birth to 2 years of age attending PMTCT services in LMICs. We will include randomized controlled trials (RCTs), cluster RCTs, non-randomized controlled trials, and interrupted time series. The primary outcomes of interest are percentage of HIV-infected women receiving/initiated on anti-retroviral prophylaxis or treatment, percentage of infants receiving/initiated on anti-retroviral prophylaxis, and percentage of women and infants completing the anti-retroviral regimen/retained in PMTCT care. The following databases will be searched from inception: Ovid MEDLINE and EMBASE, The WHO Global Health Library, CAB abstracts, EBM Reviews, CINAHL, HealthSTAR and Web of Science databases, Scopus, PsychINFO, POPLINE, Sociological Abstracts, ERIC, AIDS Education Global Information System, NLM Gateway, LILACS, Google Scholar, British Library Catalogue, DARE, ProQuest Dissertation & Theses, the New York Academy of Grey Literature, Open Grey, The Cochrane Library, WHO International Clinical Trials Registry, Controlled Clinical Trials, and clinicaltrials.gov. Reference lists of included articles will be hand searched and study authors and content experts contacted to inquire about eligible unpublished or in progress studies. Screening, data abstraction, and risk of bias appraisal using the Cochrane Effective Practice and Organization of Care criteria will be conducted independently by two team members. Results will be synthesized narratively and a meta-analysis conducted using the DerSimonian Laird random effects method if appropriate based on assessment of clinical and statistical heterogeneity.
Our findings will be useful to PMTCT implementers, policy makers, and implementation researchers working in LMICs.
PROSPERO CRD42015020829.
OBJECTIVE: To identify barriers and facilitators to efforts by lay health workers (LHWs) to support anti-tuberculosis treatment adherence in Malawi to inform the design of a knowledge translation ...intervention for improving adherence.DESIGN: Qualitative study utilizing focus groups
and interviews conducted with LHWs providing tuberculosis (TB) care in Zomba District, Malawi.RESULTS: Participants identified lack of knowledge, both general (understanding of TB and its treatment) and job-specific (understanding of tasks such as completion of treatment forms), as the
key barrier to LHWs in their role as adherence supporters. Lack of knowledge among LHWs providing TB care was reported to lead to a lack of confidence, conflicting messages given to patients, poor interactions with patients and errors in documentation. In addition to lack of knowledge, a number
of system barriers were identified as limiting LHWs' ability to function optimally, including a lack of physical resources, workload, communication delays and ineffective guardians.CONCLUSION: Our findings suggest a gap between LHW knowledge and their responsibilities as adherence supporters.
The results have informed the development of an educational outreach intervention and point-of-care tool, to be evaluated in a randomized trial in Zomba District.
Résultats: Quarante-sept articles ont été sélectionnés en vue d'un examen complet, à partir de 635 citations. La majorité (66%) de ces articles consistait en un examen rétrospectif de dossiers ...médicaux; un faible pourcentage (10.6%) concernait la médecine d'urgence et un pourcentage encore plus faible se rapportait à des études canadiennes (8.5%).
The Toronto-Addis Ababa Academic Collaboration in Emergency Medicine (TAAAC-EM) deploys teaching teams of Canadian EM faculty to Addis Ababa to deliver a longitudinal residency curriculum. Canadian ...trainees participate in these teams as a formally structured and supervised elective in global health (GH) and EM, which has been designed to enhance the strength of GH electives and address key challenges highlighted in the literature.
The purpose of this qualitative study was to identify, describe, and evaluate strengths and weaknesses of this elective in relation to its purposeful structure. Residents who completed the elective were invited to participate in face-to-face interviews to discuss their experiences.
The findings show that the residents both chose this elective because of its purposefully designed features, and that these same features increased their enjoyment and the educational benefit of the elective. Supervised bedside teaching, relationships shared with Ethiopian residents, and the positive impact the experience had on their clinical practice in Canada were identified as the primary strengths.
Purposeful and thoughtful design of global health electives can enhance the resident learning experience and mitigate challenges for trainees seeking global health training opportunities.
Despite recent advances in our understanding of paediatric pain and its management, pain continues to be undertreated globally, particularly in children and in low income countries. This article ...describes the development of a paediatric analgesia and sedation protocol, tailored to the specific setting of the Medical Research Council (MRC) paediatric ward in the Gambia, West Africa. An iterative process was used throughout development, with inputs from the medical literature, local providers, and pain experts, incorporated to ensure a safe, effective, and locally appropriate protocol. We demonstrate that evidence-based published guidelines, can and should be adapted to allow for optimal pain management given the resources and capabilities of specific health care settings. It is hoped that the process and protocol described here, will not only help to improve care on the MRC ward, but serve as an example to others working toward improving pain management in similar health care settings.
Background: Task shifting provision of basic health care services to lay health workers (LHWs) is increasingly employed to combat the global shortage of skilled health workers, particularly in low ...and middle income countries, where the shortage is greatest. Despite evidence for the effectiveness of LHWs in improving access to basic health services and positively impacting a variety of health outcomes, questions remain as to how recognized weaknesses in training and supervision are best addressed. This thesis employed a sequential-concurrent mixed-methods design and is composed of 3 studies with the objective of designing and rigorously evaluating a knowledge translation (KT) intervention tailored to address identified barriers to LHWs ability to function optimally as TB adherence supporters in Zomba district, Malawi.
Methods & Findings: The first study utilized the qualitative methods of focus groups and interviews conducted with LHWs routinely involved in provision of care to TB patients. Lack of TB knowledge and job-specific training were identified as the key barriers to LHWs in their role as TB adherence supporters. Based on these findings, a KT intervention was developed and tailored to the identified training gaps. The second study, evaluated the effectiveness of the intervention in improving TB treatment adherence in a cluster randomized controlled trial, which showed no evidence for effectiveness of the intervention. The third study, conducted concurrently with the cluster trial, employed qualitative interviews to explore LHWs experiences with the intervention to identify
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aspects of the intervention found to be helpful and areas in need of improvement. Study 3 found that the intervention was well received and valued, with reported benefits to LHWs through improved knowledge and skills, and increased confidence. Suggestions for improvement varied considerably, with an anticipated concern with the lack of stipends and conduct of training on-site, raised as an issue by a minority of participants.
Conclusion: This thesis suggests that a multi-component KT strategy tailored to address local barriers, was well received and valued by LHWs, and may represent a cost-effective approach to LHW training. However, given the trend for effectiveness did not reach significance in this underpowered study, further research is needed.
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