Insufficient awareness of the centrality of pathology and laboratory medicine (PALM) to a functioning health-care system at policy and governmental level, with the resultant inadequate investment, ...has meant that efforts to enhance PALM in low-income and middle-income countries have been local, fragmented, and mostly unsustainable. Responding to the four major barriers in PALM service delivery that were identified in the first paper of this Series (workforce, infrastructure, education and training, and quality assurance), this second paper identifies potential solutions that can be applied in low-income and middle-income countries (LMICs). Increasing and retaining a quality PALM workforce requires access to mentorship and continuing professional development, task sharing, and the development of short-term visitor programmes. Opportunities to enhance the training of pathologists and allied PALM personnel by increasing and improving education provision must be explored and implemented. PALM infrastructure must be strengthened by addressing supply chain barriers, and ensuring laboratory information systems are in place. New technologies, including telepathology and point-of-care testing, can have a substantial role in PALM service delivery, if used appropriately. We emphasise the crucial importance of maintaining PALM quality and posit that all laboratories in LMICs should participate in quality assurance and accreditation programmes. A potential role for public-private partnerships in filling PALM services gaps should also be investigated. Finally, to deliver these solutions and ensure equitable access to essential services in LMICs, we propose a PALM package focused on these countries, integrated within a nationally tiered laboratory system, as part of an overarching national laboratory strategic plan.
Access to timely and accurate diagnostic imaging is essential for high-quality healthcare. Point-of-care ultrasound has been shown to be accessible and effective in many aspects of healthcare, ...including assessing changes in lung pathology. However, few studies have examined self-administered at-home lung ultrasound (SAAH-LUS), in particular performed by non-clinical patients (NCPs).
Are NCPs able to perform SAAH-LUS using remote teleguidance and produce interpretable images?
Patients were enrolled to the study in a mix of in-person and virtual recruitment, and shipped a smartphone as well as a point of care ultrasound device. Tele-guidance was provided by a remote physician using software integrated with the point of care ultrasound device, allowing real-time remote visualization and guidance of a patient scanning their own chest. A post-intervention survey was conducted to assess patient satisfaction, feasibility, and acceptability of SAAH-LUS. Two POCUS expert reviewers reviewed the scans for interpretability, and inter-rater agreement between the two reviewers was also computed.
Eighteen patients successfully underwent 7-14 days of daily telemedicine in parallel to daily SAAH-LUS. Across 1339 scans obtained from ten different lung zones, the average proportion of interpretability was 96% with a chance-corrected agreement, or Cohen's kappa, reported as κ = 0.67 (significant agreement). 100% of NCPs surveyed found SAAH-LUS to be a positive experience, particularly for its ease of operation and ability to increase access to healthcare services.
This study demonstrates that NCPs can obtain interpretable LUS images at home, highlighting the potential for SAAH-LUS to increase diagnostic capacity, particularly for rural and remote regions where complex imaging and healthcare providers are difficult to obtain. Trial registration The clinical trials has been registered (clinicaltrials.gov).
NCT04967729.
Although most medical schools and residency programs offer international medical electives (IMEs), little guidance on the educational objectives for these rotations exists; thus, the authors reviewed ...the literature to compile and categorize a comprehensive set of educational objectives for IMEs.
In February and July 2012, the authors searched SciVerse Scopus online, which includes the Embase and MEDLINE databases, using specified terms. From the articles that met their inclusion criteria, they extracted the educational objectives of IMEs and sorted them into preelective, intraelective, and postelective objectives.
The authors identified and reviewed 255 articles, 11 (4%) of which described 22 educational objectives. Among those 22 objectives, 5 (23%), 15 (68%), and 2 (9%) were, respectively, preelective, intraelective, and postelective objectives. Among preelective objectives, only cultural awareness appeared in more than 2 articles (3/11; 27%). Among intraelective objectives, the most commonly defined were enhancing clinical skills and understanding different health care systems (9/11; 82%). Learning to manage diseases rarely seen at home and increasing cultural awareness appeared in nearly half (5/11; 45%) of all articles. Among postelective objectives, reflecting on experiences through a written project was most common (9/11; 82%).
The authors identified 22 educational objectives for IMEs in the published literature, some of which were consistent across institutions. These consistencies, in conjunction with future research, can be used as a framework on which institutions can build their own IME curricula, ultimately helping to ensure that their medical trainees have a meaningful learning experience while abroad.
In rural Uganda pregnant women often lack access to health services, do not attend antenatal care, and tend to utilize traditional healers/birth attendants. We hypothesized that receiving a message ...advertising that "you will be able to see your baby by ultrasound" would motivate rural Ugandan women who otherwise might use a traditional birth attendant to attend antenatal care, and that those women would subsequently be more satisfied with care. A cluster randomized trial was conducted across eight rural sub-counties in southwestern Uganda. Sub-counties were randomized to a control arm, with advertisement of antenatal care with no mention of portable obstetric ultrasound (four communities, n = 59), or an intervention arm, with advertisement of portable obstetric ultrasound. Advertisement of portable obstetric ultrasound was further divided into intervention A) word of mouth advertisement of portable obstetric ultrasound and antenatal care (one communitity, n = 16), B) radio advertisement of only antenatal care and word of mouth advertisement of antenatal care and portable obstetric ultrasound (one community, n = 7), or C) word of mouth + radio advertisement of both antenatal care and portable obstetric ultrasound (two communities, n = 75). The primary outcome was attendance to antenatal care. 159 women presented to antenatal care across eight sub-counties. The rate of attendance was 65.1 (per 1000 pregnant women, 95% CI 38.3-110.4) where portable obstetric ultrasound was advertised by radio and word of mouth, as compared to a rate of 11.1 (95% CI 6.1-20.1) in control communities (rate ratio 5.9, 95% CI 2.6-13.0, p<0.0001). Attendance was also improved in women who had previously seen a traditional healer (13.0, 95% CI 5.4-31.2) compared to control (1.5, 95% CI 0.5-5.0, rate ratio 8.7, 95% CI 2.0-38.1, p = 0.004). By advertising antenatal care and portable obstetric ultrasound by radio attendance was significantly improved. This study suggests that women can be motivated to attend antenatal care when offered the concrete incentive of seeing their baby.
To examine the job search, employment experiences, and job availability of recent global health-focused master's level graduates.
An online survey was conducted from October to December 2016 based ...out of Washington, DC. The study sample includes students graduating with master's degrees in global health, public health with a global health concentration or global medicine from eight U.S. universities.
Out of 256 potential respondents, 152 (59%) completed the survey, with 102/152 (67%) employed. Of unemployed graduates, 38% were currently in another educational training program. Out of 91 employed respondents, 62 (68%) reported they had limitations or gaps in their academic training. The average salary of those employed was between $40,000 and $59,000 annually. The majority of respondents reported they currently work in North America (83.5%.); however, only 31% reported the desire to work in North America following graduation.
Discrepancies exist between graduates' expectations of employment in global public health and the eventual job market. Communication between universities, students and employers may assist in curriculum development and job satisfaction for the global public health workforce.
Current competencies in global health education largely reflect perspectives from high-income countries (HICs). Consequently, there has been underrepresentation of the voices and perspectives of ...partners in low- and middle-income countries (LMICs) who supervise and mentor trainees engaged in short-term experiences in global health (STEGH).
The objective of this study was to better understand the competencies and learning objectives that are considered a priority from the perspective of partners in LMICs.
A review of current interprofessional global health competencies was performed to design a web-based survey instrument in English and Spanish. Survey data were collected from a global convenience sample. Data underwent descriptive statistical analysis and logistic regression.
The survey was completed by 170 individuals; 132 in English and 38 in Spanish. More than 85% of respondents rated cultural awareness and respectful conduct while on a STEGH as important. None of the respondents said trainees arrive as independent practitioners to fill health care gaps. Of 109 respondents, 65 (60%) reported that trainees gaining fluency in the local language was not important.
This study found different levels of agreement between partners across economic regions of the world when compared with existing global health competencies. By gaining insight into host partners' perceptions of desired competencies, global health education programs in LMICs can be more collaboratively and ethically designed to meet the priorities, needs, and expectations of those stakeholders. This study begins to shift the paradigm of global health education program design by encouraging North–South/East–West shared agenda setting, mutual respect, empowerment, and true collaboration.
Short-term, primary-care medical service trips (MSTs) are a controversial modality for addressing the health of marginalised populations and responding to the burden of communicable and ...non-communicable diseases. As a health-care delivery model, MSTs are challenged by concerns over sustainability, fragmentation of care in host communities, and degree of preparedness among volunteers. Despite the increasing prevalence of such trips, no single framework is routinely used to evaluate their quality. We aimed to develop a literature-based tool for assessing the practices of volunteer MSTs and to validate this tool among stakeholders.
We reviewed recent literature to construct a preliminary list of commonly discussed MST best practices. A multidisciplinary panel of academic experts, medical professionals, MST programme coordinators, and non-medical MST volunteers participated in a three-round e-Delphi consensus-building exercise to revise the preliminary list. A 7-point Likert scale was used, with mean scores of 4–7 resulting in rejection of the element, scores less than 2 resulting in acceptance, and scores in between being redistributed for further discussion in rounds two and three.
The preliminary framework consisted of 30 elements sorted into six domains: preparedness, impact and safety, efficiency, cost-effectiveness, sustainability, and education. The 26 stakeholders on the eDelphi panel reached consensus on 18 desirable elements to include in the final framework for an effective MST. The elements of the final framework were directly adapted to create a rating scale for medical professionals and trainees to evaluate the practices of volunteer-sending organisations listed in a large online database (http://www.medicalservicetrip.com).
Evaluation of such practices will allow volunteers to select quality opportunities with effective, sustainable health-care delivery models. Future research should extend this study by initiating a dialogue on best practices between host communities, local clinicians, and MST-sending organisations.
None.
ObjectiveCanadian family medicine (FM) residency programmes are responding to the growing demand to provide global health (GH) education to their trainees; herein, we describe the various GH ...activities (GHAs) offered within Canadian FM programmes.DesignA bilingual online survey was sent out to all 17 Canadian FM program directors (PDs) and/or an appointed GH representative.SettingOnline survey via QualtricsParticipantsAll 17 Canadian FM PDs and/or an appointed GH representative.ResultsThe response rate was 100% and represented 3250 first-year and second-year FM residents across English and French Canada. All schools stated that they participate in some form of GHAs. There was variation in the level of organisation, participation and types of GHAs offered. Overall, most GHAs are optional, and there is a large amount of variation in terms of resident participation. Approximately one third of programmes receive dedicated funding for their GHAs, and two thirds wish to increase the scope/variety of GHAs.ConclusionThese results suggest nationwide interest in developing a workforce trained in GH, but show great discrepancies in training, implementation and education.
North American clinicians are increasingly participating in medical service trips (MSTs) that provide primary healthcare in Latin America and the Caribbean. Literature reviews have shown that the ...existence and use of evidence-based guidelines by these groups are limited, which presents potential for harm.
This paper proposes a 5-step methodology to develop protocols for diagnosis and treatment of conditions encountered by MST clinicians.
We reviewed the 2010 American College of Physicians guidance statement on guidelines development and developed our own adaptation. Ancestry search of the American College of Physicians statement identified specific publications that provided additional detail on key steps in the guideline development process, with additional focus given to evidence, equity, and local adaptation considerations.
Our adaptation produced a 5-step process for developing locally optimized protocols for diagnosis and treatment of common conditions seen in MSTs. For specified conditions, this process includes: 1) a focused environmental scan of current practices based on grey literature protocols from MST sending organizations; 2) a review of relevant practice guidelines; 3) a literature review assessing the epidemiology, diagnosis, and treatment of the specified condition; 4) an eDelphi process with experts representing MST and Latin American and the Caribbean partner organizations assessing identified guidelines; and 5) external peer review and summary.
This protocol will enable the creation of practice guidelines that are based on best available evidence, local knowledge, and equitable considerations. The development of guidelines using this process could optimize the conduct of MSTs, while prioritizing input from local community partners.
Abstract Background Competencies developed for global health education programmes that take place in low-income and middle-income countries have largely reflected the perspectives of educators and ...organisations in high-income countries. Consequently, there has been under-representation of voices and perspectives of host communities, where practical, experience-based global-health education occurs. In this study, we aimed to understand what global-health competencies are important in trainees who travel to work in other countries, seeking opinions from host community members and colleagues in low-income and middle-income countries. Methods We performed a literature review of current interprofessional global health competencies to inform our survey design. We used a web-based survey, available in English and Spanish, to collect data through Likert-scale and written questions. We piloted the survey in a diverse group of 14 respondents from high-income, middle-income, and low-income countries and subsequently refined the survey for greater clarity. We used convenience sampling to recruit participants from around the world and included a broad range of coauthors. A website was constructed in English and Spanish and the survey link added. This website and link were distributed as broadly as possible. It was mandatory for survey participants to list their country of birth and current work in order to confirm representation. Findings We received 274 responses: 227 in English and 47 in Spanish between Sept 1, 2015, and Dec 31, 2015. Respondents were from 38 countries across all economic regions. After data cleaning, we included 170 responses (132 in English and 38 in Spanish): 44 (26%) from high-income countries, 74 (44%) from upper-middle income countries, 31 (18%) from lower-middle income countries, and 21 (12%) from low-income countries. Respondents spoke 22 distinct primary languages. In terms of pre-departure competencies, 111 respondents rated cultural awareness and respectful conduct while on rotations as important. For intra-experience competencies, 88 of 112 respondents (79%) thought that it was equally as important for trainees to learn about the local culture as it was to learn about medical conditions. 65 of 109 (60%) respondents reported trainees gaining fluency in the local language as being not important. In terms of post-experience competencies, none of the respondents reported that trainees arrive as independent practitioners to fill health-care gaps. Interpretation Most hosts and partners across economic regions appreciate having trainees from other countries in their institutions and communities. There was a strong emphasis from respondents on the importance of a greater focus on cultural learning and building respect over medical knowledge and clinical practice. Additionally, respondents did not believe that trainees fill important human resource gaps, but are instead being provided with a beneficial learning experience. By gaining insight into host perceptions on desired competencies, global health education programmes in low-income and middle-income countries can be collaboratively and ethically designed and implemented to meet the priorities, needs, and expectations of host communities. Our findings could change how global health education programmes are structured, by encouraging North-South/East-West shared agenda setting, mutual respect, empowerment, and collaboration. Funding Child Family Health International.
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