Medical Education in Decentralized Settings: How Medical Students Contribute to Health Care in 10 Sub-Saharan African Countries

Purpose: African medical schools are expanding, straining resources at tertiary health facilities. Decentralizing clinical training can alleviate this tension. This study assessed the impact of decentralized training and contribution of undergraduate medical students at health facilities. Method: Participants were from 11 Medical Education Partnership Initiative-funded medical schools in 10 African countries. Each school identified two clinical training sites-one rural and the other either peri-urban or urban. Qualitative and quantitative data collection tools were used to gather information about the sites, student activities, and staff perspectives between March 2015 and February 2016. Interviews with site staff were analyzed using a collaborative directed approach to content analysis, and frequencies were generated to describe site characteristics and student experiences. Results: The clinical sites varied in level of care but were similar in scope of clinical services and types of clinical and nonclinical student activities. Staff indicated that students have a positive effect on job satisfaction and workload. Respondents reported that students improved the work environment, institutional reputation, and introduced evidence-based approaches. Students also contributed to perceived improvements in quality of care, patient experience, and community outreach. Staff highlighted the need for resources to support students. Conclusions: Students were seen as valuable resources for health facilities. They strengthened health care quality by supporting overburdened staff and by bringing rigor and accountability into the work environment. As medical schools expand, especially in low-resource settings, mobilizing new and existing resources for decentralized clinical training could transform health facilities into vibrant service and learning environments

Trends and Predictors of Virologic Failure Following Suppression on Antiretroviral Therapy among HIV Infected Children in Kenya

Thesis (Master's)--University of Washington, 2016-08Background: There are limited data on the incidence and predictors of virologic failure among HIV infected children on antiretroviral treatment (ART), particularly among children who have previously suppressed virus. We examined incidence, timing, and correlates of virologic failure following suppression in a longitudinal cohort of children on ART. Methods: This analysis utilized data from a prospective cohort study among children 15 months to 12 years old, with moderate to severe HIV disease who were initiated on ART and followed for up to 5.5 years with 3-monthly measurement of plasma HIV RNA levels. Virologic failure was defined as presence of detectable HIV RNA in plasma after achieving viral suppression (<500 copies/ml). A time to event analysis of virologic failure from viral suppression was conducted and predictors of time to virologic failure were determined using Cox proportional hazards regression models. Results: Overall, 149 children were initiated on ART with a median time of follow-up time of 49 months (IQR 35, 60 months). Ninety-four (63.1%) children achieved plasma viral suppression, among whom 32 (34.4%) experienced virologic rebound after suppression with an incidence rate of 13.8 failures/100 person-years. Children whose caregivers were housewives or unemployed were significantly less likely to fail following suppression (HR: 0.34, 95%CI: 0.16, 0.72; P=0.005). Caregivers who did not know if their spouses had been HIV tested were more likely to fail on treatment [HR: 2.48, 95%CI: 1.02, 5.99 P=0.04). There was a trend towards failure among children who were visibly wasted at baseline and those who were initiated on a stavudine- based regimen [HR: 1.86; 95%CI: 0.93, 3.73; P=0.08] and [HR: 1.97, 95%CI: 0.96, 4.04 P=0.06] respectively. Conclusion: We found high rates of virologic failure among HIV infected children on ART despite initial suppression. Caregivers play a critical role in ensuring children’s success on ART and may need programmatic strategies to support their roles. Recognition of children at risk for failure can complement scale up of virologic testing capacity to ensure better outcomes

Beyond signal functions in global obstetric care: Using a clinical cascade to measure emergency obstetric readiness.

BackgroundGlobally, the rate of reduction in delivery-associated maternal and perinatal mortality has been slow compared to improvements in post-delivery mortality in children under five. Improving clinical readiness for basic obstetric emergencies is crucial for reducing facility-based maternal deaths. Emergency readiness is commonly assessed using tracers derived from the maternal signal functions model.Objective-methodWe compare emergency readiness using the signal functions model and a novel clinical cascade. The cascades model readiness as the proportion of facilities with resources to identify the emergency (stage 1), treat it (stage 2) and monitor-modify therapy (stage 3). Data were collected from 44 Kenyan clinics as part of an implementation trial.FindingsAlthough most facilities (77.0%) stock maternal signal function tracer drugs, far fewer have resources to practically identify and treat emergencies. In hypertensive emergencies for example, 38.6% of facilities have resources to identify the emergency (Stage 1 readiness, including sphygmomanometer, stethoscope, urine collection device, protein test). 6.8% have the resources to treat the emergency (Stage 2, consumables (IV Kit, fluids), durable goods (IV pole) and drugs (magnesium sulfate and hydralazine). No facilities could monitor or modify therapy (Stage 3). Across five maternal emergencies, the signal functions overestimate readiness by 54.5%. A consistent, step-wise pattern of readiness loss across signal functions and care stage emerged and was profoundly consistent at 33.0%.SignificanceComparing estimates from the maternal signal functions and cascades illustrates four themes. First, signal functions overestimate practical readiness by 55%. Second, the cascade's intuitive indicators can support cross-sector health system or program planners to more precisely measure and improve emergency care. Third, adding few variables to existing readiness inventories permits step-wise modeling of readiness loss and can inform more precise interventions. Fourth, the novel aggregate readiness loss indicator provides an innovative and intuitive approach for modeling health system emergency readiness. Additional testing in diverse contexts is warranted

Beyond signal functions in global obstetric care: Using a clinical cascade to measure emergency obstetric readiness.

BackgroundGlobally, the rate of reduction in delivery-associated maternal and perinatal mortality has been slow compared to improvements in post-delivery mortality in children under five. Improving clinical readiness for basic obstetric emergencies is crucial for reducing facility-based maternal deaths. Emergency readiness is commonly assessed using tracers derived from the maternal signal functions model.Objective-methodWe compare emergency readiness using the signal functions model and a novel clinical cascade. The cascades model readiness as the proportion of facilities with resources to identify the emergency (stage 1), treat it (stage 2) and monitor-modify therapy (stage 3). Data were collected from 44 Kenyan clinics as part of an implementation trial.FindingsAlthough most facilities (77.0%) stock maternal signal function tracer drugs, far fewer have resources to practically identify and treat emergencies. In hypertensive emergencies for example, 38.6% of facilities have resources to identify the emergency (Stage 1 readiness, including sphygmomanometer, stethoscope, urine collection device, protein test). 6.8% have the resources to treat the emergency (Stage 2, consumables (IV Kit, fluids), durable goods (IV pole) and drugs (magnesium sulfate and hydralazine). No facilities could monitor or modify therapy (Stage 3). Across five maternal emergencies, the signal functions overestimate readiness by 54.5%. A consistent, step-wise pattern of readiness loss across signal functions and care stage emerged and was profoundly consistent at 33.0%.SignificanceComparing estimates from the maternal signal functions and cascades illustrates four themes. First, signal functions overestimate practical readiness by 55%. Second, the cascade's intuitive indicators can support cross-sector health system or program planners to more precisely measure and improve emergency care. Third, adding few variables to existing readiness inventories permits step-wise modeling of readiness loss and can inform more precise interventions. Fourth, the novel aggregate readiness loss indicator provides an innovative and intuitive approach for modeling health system emergency readiness. Additional testing in diverse contexts is warranted

Comparison of emergency readiness using clinical cascades and signal functions.

<p>Comparison of emergency readiness using clinical cascades and signal functions.</p

Incomplete abortion clinical cascade.

<p>Incomplete abortion clinical cascade.</p

Hypertensive emergency clinical cascade.

<p>Hypertensive emergency clinical cascade.</p

Signal function versus clinical cascade estimates of emergency readiness.

<p>Signal function versus clinical cascade estimates of emergency readiness.</p

Cascade emergency readiness stratified by manual signal function.

<p>Cascade emergency readiness stratified by manual signal function.</p

Emergency readiness estimates by emergency cascade and stage.

<p>Emergency readiness estimates by emergency cascade and stage.</p