Blended teaching and learning: Exploring the concept, barriers to implementation and designing of learning resources

With the advent of the coronavirus disease 2019 (COVID-19), several institutions worldwide have adopted the blended mode of teaching and learning. However, literature on this concept in South Africa and on the African continent is scarce. This scoping review explores the concept of blended approach to training and how to design resources for the blended teaching and learning approach. In addition, the review investigates barriers to the implementation of blended learning. The findings of this study demonstrate that the understanding of the concept of blended teaching and learning is not homogenous and is often left to individual academics to decide on the approach. The review identified several hurdles that need to be addressed for successful implementation of blended teaching and learning, however these are not specific to South African institutions. Available literature on studies done elsewhere and in South African, suggest that some of the identified barriers to adoption of blended teaching and learning are real, while others are perceived or imagined. Lastly, the authors observed that there are several approaches to designing learning resources for the blended mode of teaching and learning. The choice of approach is dependent on the intended purpose for which the specific design is adopted. There is a need for studies that specifically investigate blended learning in Universities in South Africa and on the continent to help identify barriers to adopting blended teaching and learning among institutions that are specific to the South African and African context. Institutions adopting the blended teaching and learning mode of delivery, need to be unambiguous in their philosophy of blending teaching and learning and not leave it to the implementing academics. Policymakers can use the information generated in this review to recommend minimum requirements for a blended delivery mode in public institutions of higher learning

Health care provider decision-making and the quality of maternity care: an analysis of postpartum care in Kenyan hospitals

Evidence suggests that health care providers' non-adherence to clinical guidelines is widespread and contributes to poor patient outcomes across low- and middle-income countries. Through observations of maternity care in Kenya, we found limited adherence to guideline-recommended active monitoring of patients for signs of postpartum hemorrhage, the leading cause of maternal mortality, despite providers' having the necessary training and equipment. Using survey vignettes conducted with 144 maternity providers, we documented evidence consistent with subjective risk and perceived uncertainty driving providers' decisions to actively monitor patients. Motivated by these findings, we introduced a simple model of providers' decision-making about whether to monitor a patient, which may depend on their perceptions of risk, diagnostic uncertainty, and the value of new information. The model highlights key trade-offs between gathering diagnostic information through active monitoring versus waiting for signs and symptoms of hemorrhage to manifest. Our work provides a template for understanding provider decision-making and could inform interventions to encourage more proactive obstetric care

Health care providers' knowledge of clinical protocols for postpartum hemorrhage care in Kenya: a cross-sectional study

BACKGROUND: Postpartum hemorrhage (PPH) remains the leading cause of maternal death worldwide despite its often-preventable nature. Understanding health care providers' knowledge of clinical protocols is imperative for improving quality of care and reducing mortality. This is especially pertinent in referral and teaching hospitals that train nursing and medical students and interns in addition to managing emergency and referral cases. METHODS: This study aimed to (1) measure health care providers' knowledge of clinical protocols for risk assessment, prevention, and management of PPH in 3 referral hospitals in Kenya and (2) examine factors associated with providers' knowledge. We developed a knowledge assessment tool based on past studies and clinical guidelines from the World Health Organization and the Kenyan Ministry of Health. We conducted in-person surveys with health care providers in three high-volume maternity facilities in Nairobi and western Kenya from October 2018-February 2019. We measured gaps in knowledge using a summative index and examined factors associated with knowledge (such as age, gender, qualification, experience, in-service training attendance, and a self-reported measure of peer-closeness) using linear regression. RESULTS: We interviewed 172 providers including consultants, medical officers, clinical officers, nurse-midwives, and students. Overall, knowledge was lowest for prevention-related protocols (an average of 0.71 out of 1.00; 95% CI 0.69-0.73) and highest for assessment-related protocols (0.81; 95% CI 0.79-0.83). Average knowledge scores did not differ significantly between qualified providers and students. Finally, we found that being a qualified nurse, having a specialization, being female, having a bachelor's degree and self-reported closer relationships with colleagues were statistically significantly associated with higher knowledge scores. CONCLUSION: We found gaps in knowledge of PPH care clinical protocols in Kenya. There is a clear need for innovations in clinical training to ensure that providers in teaching referral hospitals are prepared to prevent, assess, and manage PPH. It is possible that training interventions focused on learning by doing and teamwork may be beneficial

Provider experiences with improvised uterine balloon tamponade for the management of uncontrolled postpartum hemorrhage in Kenya

AbstractObjectiveTo understand healthcare providers’ experiences with improvised uterine balloon tamponade (UBT) for the management of uncontrolled postpartum hemorrhage (PPH).MethodsIn a qualitative descriptive study, in-depth semi-structured interviews were conducted between November 2014 and June 2015 among Kenyan healthcare providers who had previous experience with improvising a UBT device. Interviews were conducted, audio-recorded, and transcribed.ResultsOverall, 29 healthcare providers (14 nurse-midwifes, 7 medical officers, 7 obstetricians, and 1 clinical officer) were interviewed. Providers perceived improvised UBT as valuable for managing uncontrolled PPH. Reported benefits included effectiveness in arresting hemorrhage and averting hysterectomy, and ease of use by providers of all levels of training. Providers used various materials to construct an improvised UBT. Challenges to improvising UBT—e.g. searching for materials during an emergency, procuring male condoms, and inserting fluid via a small syringe—were reported to lead to delays in care. Providers described their introduction to improvised UBT through both formal and informal sources. There was universal enthusiasm for widespread standardized training.ConclusionImprovised UBT seems to be a valuable second-line treatment for uncontrolled PPH that can be used by providers of all levels. UBT might be optimized by integrating a standard package across the health system

Successful interruption of the transmission of Onchocerca volvulus in Mpamba-Nkusi focus, Kibaale district, mid-western Uganda

Background: The Mpamba-Nkusi onchocerciasis focus is situated in the mid-western part of Uganda. It has an area of 300 km2 and used to have Simulium neavei as the vector which develops in a phoretic association on freshwater crabs. Ground larviciding with temephos (Abate EC500) was initiated in June 2002. All the 330 communities in this focus have undergone annual treatment with ivermectin since 1995 and were later shifted to semi-annual treatment in 2009.Objective: To establish the impact of mass drug administration in combination with larviciding on the interruption of O. volvulus transmission.Design: Longitudinal studySetting: Rural areas in Mpamba-Nkusi focus, Kibaale district.Subjects: Individuals five years and above living in the focus.Interventions: Annual and semi-annual treatment with ivermectin supplemented by vector elimination were used. Epidemiological, entomological and serological assessments were conducted.Results: Freshwater crabs (n = 14,391) caught from monitoring sites (n = 41) since 2008 were negative for immature stages of S. neavei. The S.neavei population was reduced following trial and initiation of ground larviciding. No adult S. neavei has been caught in the focus for over five years. Parasitological examination of individuals residing in the focus revealed a microfilaria (mf) prevalence of 0.3% (95% CI 0 – 0.65%; n = 732) in 2012. Serological assays testing for Onchocerca volvulus antibodies conducted on 3351 children <15 years in 2009 indicated point prevalence of 0.6% , (95% CI, 0.3-0.8%) while in 2012 another survey conducted among 3,407 children, only 1/3407 (0.03%, 95% CI, 0-0.09%) individual was positive for O. volvulus antibodies.Conclusions: Epidemiological and entomological findings suggest that interruption of transmission has been achieved

Safety of a condom uterine balloon tamponade (ESM-UBT) device for uncontrolled primary postpartum hemorrhage among facilities in Kenya and Sierra Leone

Background: Postpartum hemorrhage is the leading cause of maternal mortality in low- and middle-income countries. While evidence on uterine balloon tamponade efficacy for severe hemorrhage is encouraging, little is known about safety of this intervention. The objective of this study was to evaluate the safety of an ultra-low-cost uterine balloon tamponade package (named ESM-UBT) for facility-based management of uncontrolled postpartum hemorrhage (PPH) in Kenya and Sierra Leone. Methods: Data were collected on complications/adverse events in all women who had an ESM-UBT device placed among 92 facilities in Sierra Leone and Kenya, between September 2012 and December 2015, as part of a multi-country study. Three expert maternal health investigator physicians analyzed each complication/adverse event and developed consensus on whether there was a potential causal relationship associated with use of the ESM-UBT device. Adverse events/complications specifically investigated included death, hysterectomy, uterine rupture, perineal or cervical injury, serious or minor infection, and latex allergy/anaphylaxis. Results: Of the 201 women treated with an ESM-UBT device in Kenya and Sierra Leone, 189 (94.0%) survived. Six-week or longer follow-up was recorded in 156 of the 189 (82.5%). A causal relationship between use of an ESM-UBT device and one death, three perineal injuries and one case of mild endometritis could not be completely excluded. Three experts found a potential association between these injuries and an ESM-UBT device highly unlikely. Conclusion: The ESM-UBT device appears safe for use in women with uncontrolled PPH. Trial registration Trial registration was not completed as data was collected as a quality assurance measure for the ESM-UBT kit

Sensitivity and Specificity of Multiple Kato-Katz Thick Smears and a Circulating Cathodic Antigen Test for Schistosoma mansoni Diagnosis Pre- and Post-repeated-Praziquantel Treatment

Two Kato-Katz thick smears (Kato-Katzs) from a single stool are currently recommended for diagnosing Schistosoma mansoni infections to map areas for intervention. This ‘gold standard’ has low sensitivity at low infection intensities. The urine point-of-care circulating cathodic antigen test (POC-CCA) is potentially more sensitive but how accurately they detect S. mansoni after repeated praziquantel treatments, their suitability for measuring drug efficacy and their correlation with egg counts remain to be fully understood. We compared the accuracies of one to six Kato-Katzs and one POC-CCA for the diagnosis of S. mansoni in primary-school children who have received zero to ten praziquantel treatments. We determined the impact each diagnostic approach may have on monitoring and evaluation (M&E) and drug-efficacy findings

Nurse-midwives’ ability to diagnose acute third- and fourth-degree obstetric lacerations in western Kenya

Background: Obstetric fistula devastates the lives of women and is found most commonly among the poor in resource-limited settings. Unrepaired third- and fourth-degree perineal lacerations have been shown to be the source of approximately one-third of the fistula burden in fistula camps in Kenya. In this study, we assessed potential barriers to accurate identification by Kenyan nurse-midwives of these complex perineal lacerations in postpartum women. Methods: Nurse-midwife trainers from each of the seven sub-counties of Siaya County, Kenya were assessed in their ability to accurately identify obstetric lacerations and anatomical structures of the perineum, using a pictorial assessment tool. Referral pathways, follow-up mechanisms, and barriers to assessing obstetric lacerations were evaluated. Results: Twenty-two nurse-midwife trainers were assessed. Four of the 22 (18.2%) reported ever receiving formal training on evaluating third- and fourth-degree obstetric lacerations, and 20 of 22 (91%) reported health-system challenges to adequately completing their examination of the perineum at delivery. Twenty-one percent of third- and fourth-degree obstetric lacerations in the pictorial assessment were incorrectly identified as first- or second-degree lacerations. Conclusion: County nurse-midwife trainers in Siaya, Kenya, experience inadequate training, equipment, staffing, time, and knowledge as barriers to adequate diagnosis and repair of third- and fourth-degree perineal tears

Investigating portable fluorescent microscopy (CyScope®) as an alternative rapid diagnostic test for malaria in children and women of child-bearing age

<p>Abstract</p> <p>Background</p> <p>Prompt and correct diagnosis of malaria is crucial for accurate epidemiological assessment and better case management, and while the gold standard of light microscopy is often available, it requires both expertise and time. Portable fluorescent microscopy using the CyScope^®offers a potentially quicker, easier and more field-applicable alternative. This article reports on the strengths, limitations of this methodology and its diagnostic performance in cross-sectional surveys on young children and women of child-bearing age.</p> <p>Methods</p> <p>552 adults (99% women of child-bearing age) and 980 children (99% ≤ 5 years of age) from rural and peri-urban regions of Ugandan were examined for malaria using light microscopy (Giemsa-stain), a lateral-flow test (Paracheck-Pf^®) and the CyScope^®. Results from the surveys were used to calculate diagnostic performance (sensitivity and specificity) as well as to perform a receiver operating characteristics (ROC) analyses, using light microscopy as the gold-standard.</p> <p>Results</p> <p>Fluorescent microscopy (qualitative reads) showed reduced specificity (<40%), resulting in higher community prevalence levels than those reported by light microscopy, particularly in adults (+180% in adults and +20% in children). Diagnostic sensitivity was 92.1% in adults and 86.7% in children, with an area under the ROC curve of 0.63. Importantly, optimum performance was achieved for higher parasitaemia (>400 parasites/μL blood): sensitivity of 64.2% and specificity of 86.0%. Overall, the diagnostic performance of the CyScope was found inferior to that of Paracheck-Pf^®.</p> <p>Discussion</p> <p>Fluorescent microscopy using the CyScope^®is certainly a field-applicable and relatively affordable solution for malaria diagnoses especially in areas where electrical supplies may be lacking. While it is unlikely to miss higher parasitaemia, its application in cross-sectional community-based studies leads to many false positives (i.e. small fluorescent bodies of presently unknown origin mistaken as malaria parasites). Without recourse to other technologies, arbitration of these false positives is presently equivocal, which could ultimately lead to over-treatment; something that should be further explored in future investigations if the CyScope^®is to be more widely implemented.</p