PREVALENCE of psychiatric morbidity in a community sample in Western Kenya

Background:About 25% of the worldwide population suffers from mental, neurological and substance use disorders but unfortunately, up to 75% of affected persons do not have access to the treatment they need. Data on the magnitude of the mental health problem in Kenya is scarce. The objectives of this study were to establish the prevalence and the socio-demographic factors associated with mental and substance use disorders in Kosirai division, Nandi County, Western Kenya. Methods:This was a cross sectional descriptive study in which participants were selected by simple random sampling. The sampling frame was obtained from a data base of the population in the study area developed during door-to-door testing and counseling exercises for HIV/AIDS. Four hundred and twenty consenting adults were interviewed by psychologists using the Mini International Neuropsychiatric Interview Version 7 for Diagnostic and Statistical Manual 5th Edition and a researcher-designed social demographic questionnaire. Results:One hundred and ninety one (45%) of the participants had a lifetime diagnosis of at least one of the mental disorders. Of these, 66 (15.7%) had anxiety disorder, 53 (12.3%) had major depressive disorder; 49 (11.7%) had alcohol and substance use disorder. 32 (7.6%) had experienced a psychotic episode and 69 (16.4%) had a life-time suicidal attempt. Only 7 (1.7%) had ever been diagnosed with a mental illness. Having a mental condition was associated with age less than 60 years and having a medical condition. Conclusion:A large proportion of the community has had a mental disorder in their lifetime and most of these conditions are undiagnosed and therefore not treated. These findings indicate a need for strategies that will promote diagnosis and treatment of community members with psychiatric disorders. In order to screen more people for mental illness, we recommend further research to evaluate a strategy similar to the home based counseling and testing for HIV and the use of simple screening tools

The role of community health workers in the surgical cascade: A scoping review

BACKGROUND: Community health workers (CHWs) can increase access to various primary healthcare services; however, their potential for improving surgical care is under-explored. We sought to assess the role of CHWs in the surgical cascade, defined as disease screening, linkage to operative care, and post-operative care. Given the well-described literature on CHWs and screening, we focused on the latter two steps of the surgical cascade. METHODS: We conducted a scoping review of the peer-reviewed literature. We searched for studies published in any language from January 1, 2000 to May 1, 2020 using electronic literature databases including Pubmed/MEDLINE, Web of Science, SCOPUS, and Google Scholar. We included articles on CHW involvement in linkage to operative care and/or post-operative surgical care. Narrative and descriptive methods were used to analyze the data. RESULTS: The initial search identified 145 articles relevant to steps in the surgical cascade. Ten studies met our inclusion criteria and were included for review. In linkage to care, CHWs helped increase surgical enrollment, provide resources for vulnerable patients, and build trust in healthcare services. Post-operatively, CHWs acted as effective monitors for surgical-site infections and provided socially isolated patients with support and linkage to additional services. The complex and wide-ranging needs of surgical patients illustrated the need to view surgical care as a continuum rather than a singular operative event. CONCLUSION: While the current literature is limited, CHWs were able to maneuver complex medical, cultural, and social barriers to surgical care by linking patients to counseling, education, and community resources, as well as post-operative infection prevention services. Future studies would benefit from more rigorous study designs and larger sample sizes to further elucidate the role CHWs can serve in the surgical cascade

Enhancing the Prospects for Palliative Care at the End of Life: A Statewide Educational Demonstration Project to Improve Advance Care Planning

Although patients want to participate in discussions and decisions about their end-of-life care, studies show that providers frequently fail to invite them to explore advanced care preferences or goals for living. The purpose of our demonstration project was to provide education and coaching to individuals, health providers, and organizations across the state of Indiana intended to facilitate these conversations, documenting and honoring individuals' life goals and preferences for care during the final stages of life. Education and training engaged community members as well as healthcare providers to: (1) improve participant comfort and facility discussing end-of-life issues; (2) improve knowledge of healthcare choices, including palliative and hospice care; and (3) prepare all participants to explore and document personal values, life goals, and priorities as well as goals of care. Between January of 2013 and June of 2015, the team educated close to 5,000 participants. Participants' ratings of the quality and perceived usefulness of the educational events ranged from 4 to 5 (using a 5-point scale, with 5 = most effective). Participant comments were overwhelmingly favorable and indicated an intention to put the advance care planning resources, communication skills, knowledge of palliative and hospice care, and personal renewal techniques into practice. Participant motivation to foster advance care planning, discussions of palliative care, and end-of-life conversations was facilitated by the reframing of these conversations as identifying goals of care and priorities for living well during an important stage of life. Successful strategies included helping providers and patients to adopt a broader meaning for “sustaining hope” (not for cure, but for engaging in highly valued activities), developing provider communication skills and comfort in initiating potentially difficult discussions, engaging a new community health workforce who will develop trusting relationships with patients in home-based services, and fostering self-awareness and self-care among palliative care providers

Development and use of an instrument adapted to assess the clinical skills learning environment in the pre-clinical years

BACKGROUND: The Communication, Curriculum, and Culture (C3) instrument is a well-established survey for measuring the professional learning climate or hidden curriculum in the clinical years of medical school. However, few instruments exist for assessing professionalism in the pre-clinical years. We adapted the C3 instrument and assessed its utility during the pre-clinical years at two U.S. medical schools. METHODS: The ten-item Pre-Clinical C3 survey was adapted from the C3 instrument. Surveys were administered at the conclusion of the first and second years of medical school using a repeated cross-sectional design. Factor analysis was performed and Cronbach's alphas were calculated for emerging dimensions. RESULTS: The authors collected 458 and 564 surveys at two medical schools during AY06-07 and AY07-09 years, respectively. Factor analysis of the survey data revealed nine items in three dimensions: "Patients as Objects", "Talking Respectfully of Colleagues", and "Patient-Centered Behaviors". Reliability measures (Cronbach's alpha) for the Pre-Clinical C3 survey data were similar to those of the C3 survey for comparable dimensions for each school. Gender analysis revealed significant differences in all three dimensions. CONCLUSIONS: The Pre-Clinical C3 instrument's performance was similar to the C3 instrument in measuring dimensions of professionalism. As medical education moves toward earlier and more frequent clinical and inter-professional educational experiences, the Pre-Clinical C3 instrument may be especially useful in evaluating the impact of curricular revisions

Fostering reciprocity in global health partnerships through a structured, hands-on experience for visiting postgraduate medical trainees

BACKGROUND: Global health programs that allow international experiences for US learners should also enable reciprocal learning experiences for international learners, particularly if that is a need identified by the partner institution. METHODS: A partnership between Indiana University and Moi University, Kenya, has successfully hosted 41 visiting Kenyan internal medicine and pediatrics registrars at Indiana University since 2006. The program's logistics, curriculum, and evaluation are described. RESULTS: The registrars rotated through nephrology, cardiology, hematology and oncology, infectious diseases, and intensive care, as well as related ambulatory experiences, functioning on a level comparable to fourth-year medical students. They showed significant improvement in pretest and posttest scores on a standardized National Board of Medical Examiners examination (P  =  .048). International learners experienced culture shock, yet they felt the Indiana University elective was helpful and would recommend it to future participants. CONCLUSIONS: Global health programs can reciprocate the benefits derived for US students and residents by offering learning experiences to international learners if that is an expressed need from the international partner. Barriers to those experiences can be overcome, and the hands-on, elective experience has the potential to positively affect the knowledge and attitudes of participants as well as the home nation

Evaluation of interprofessional relational coordination and patients’ perception of care in outpatient oncology teams

This pilot study was designed to measure teamwork and the relationship of teamwork to patient perceptions of care among 63 members of 12 oncology teams at a Cancer Centre in the Midwest. Lack of teamwork in cancer care can result in serious clinical errors, fragmentation of care, and poor quality of care. Many oncology team members, highly skilled in clinical care, are not trained to work effectively as members of a care team. The research team administered the Relational Coordination survey to core oncology team members—medical oncologists, nurse coordinators, and clinical secretaries—to measure seven dimensions of team skills (four relating to communication [frequency, timeliness, accuracy, and problem solving] and three relating to relationship [shared goals, shared knowledge, and mutual respect]) averaged to create a Relational Coordination Index. The results indicated that among the team member roles, nurse coordinator relational coordination indices were the strongest and most positively correlated with patient perception of care. Statistically significant correlations were intra-nurse coordinator relational coordination indices and two patient perception of care factors (information and education and patient’s preferences). All other nurse coordinator intra-role as well as inter-role correlations were also positively correlated, although not statistically significant

Impact of Community Health Workers on Elderly Patients' Advance Care Planning and Health Care Utilization: Moving the Dial

BACKGROUND: Advance care planning (ACP) is recommended for all persons to ensure that the care they receive aligns with their values and preferences. OBJECTIVE: To evaluate an ACP intervention developed to better meet the needs and priorities of persons with chronic diseases, including mild cognitive impairment. RESEARCH DESIGN: A year-long, pre-post intervention using lay community health workers [care coordinator assistants (CCAs)] trained to conduct and document ACP conversations with patients during home health visits with pre-post evaluation. SUBJECTS: The 818 patients were 74.2 years old (mean); 78% women; 51% African American; 43% white. MEASURES: Documentation of ACP conversation in electronic health record fields and health care utilization outcomes. RESULTS: In this target population ACP documentation rose from 3.4% (pre-CCA training) to 47.9% (post) of patients who had at least 1 discussion about ACP in the electronic health record. In the 1-year preintervention period, there were no differences in admissions, emergency department (ED) visits, and outpatient visits between patients who did and did not have ACP discussion. After adjusting for prior hospitalization and ED use histories, ACP discussions were associated with a 34% less probability of hospitalization (hazard ratios, 0.66; 95% confidence interval, 0.45-0.97), and similar effects are apparent on ED use independent of age and prior ED use effects. CONCLUSIONS: Patients with chronic diseases including mild cognitive impairment can engage in ACP conversations with trusted home health care providers. Having ACP conversation is associated with significant reduction in seeking urgent health care and in hospitalizations

Clarifying Values and Preferences for Care Near the End of Life: The Role of a New Lay Workforce

Community health workers (CHWs) can engage elderly persons in advance care planning (ACP) conversations. We report how trained CHWs used Go Wish cards (GW R cards) to identify patients' highest priority preferences and evaluated whether engaging in ACP conversations was associated with subsequent health care utilization. A one-year long, pre-post longitudinal design was used to evaluate our educational intervention using mixed-methods. 392 patients (mean of 73.3 years, 82% women, 48% African American, 43% Caucasian) enrolled in the Aging Brain Care (ABC) program and participated in ACP discussions with CHWs. We expanded the role of the ABC's CHW, who work directly with individuals and caregivers during home visits to monitor bio-psycho-social needs, to include ACP conversations. The CHWs received ACP training, practice with tools such as GW R cards, and support from an electronic health record (EHR) clinical decision support tool. Quantitative measures of patients' ACP preferences and health care utilization were abstracted from the EHR. Qualitative data about patients' perceptions of CHWs in facilitating ACP discussions was obtained through semi-structured interviews. Eighty-six patients' data indicated that they had engaged in a preferences-for-care process using GW R cards. The top-three card choices by patients was attending to spirituality and religious concerns, preparing for end of life, and maintaining personal wholeness. CHWs were able to effectively engage in ACP conversations with patients and GW R cards were a positive way to stimulate discussion of issues previously undiscussed

Response to depression treatment in the Aging Brain Care Medical Home model

OBJECTIVE: To evaluate the effect of the Aging Brain Care (ABC) Medical Home program's depression module on patients' depression severity measurement over time. DESIGN: Retrospective chart review. SETTING: Public hospital system. PARTICIPANTS: Patients enrolled in the ABC Medical Home program between October 1, 2012 and March 31, 2014. METHODS: The response of 773 enrolled patients who had multiple patient health questionnaire-9 (PHQ-9) scores recorded in the ABC Medical Home program's depression care protocol was evaluated. Repeatedly measured PHQ-9 change scores were the dependent variables in the mixed effects models, and demographic and comorbid medical conditions were tested as potential independent variables while including random effects for time and intercept. RESULTS: Among those patients with baseline PHQ-9 scores >10, there was a significant decrease in PHQ-9 scores over time (P50% decline from baseline) on the PHQ-9 at 6 months. CONCLUSION: These analyses demonstrate evidence for the sustained effectiveness of the ABC Medical Home program at inducing depression remission outcomes while employing clinical staff who required less formal training than earlier clinical trials

Regenstrief teaching electronic medical record (tEMR) platform: a novel tool for teaching and evaluating applied health information technology

The objective of this study is to provide an overview of the Regenstrief Teaching Electronic Medical Record (tEMR), how the tEMR could be used, and how it is currently being used in health professions education. The tEMR is a derivative of a real-world electronic health record (EHR), a large, pseudonymized patient database, and a population health tool designed to support curricular goals. The tEMR has been successfully adopted at 12 health professional, public health, and health information technology (HIT) schools, with over 11 800 unique student users and more than 74 000 logins, for case presentation, to develop diagnostic and therapeutic plans, and to practice documentation skills. With the exponential growth of health-related data and the impact of HIT on work-life balance, it is critical for students to get early EHR skills practice and understand how EHR’s work. The tEMR is a promising, scalable, flexible application to help health professional students learn about common HIT tools and issues