Examining medical doctors’ internship training experience and labour market transition in Kenya

Kenya has a severe shortage of doctors. Despite medical schools increasing the numbers of medical officers (MO) in training, less than half of newly qualified/registered MOs were absorbed by the public sector between 2015 and 2018. It seems timely to understand the labour market for this profession in system terms and in personal terms for doctors, especially during their labour market entry. I used a multiple-method approach including literature reviews, quantitative survey and qualitative interviews to examine doctors’ internship training experiences and labour market transition in Kenya. I found that the resources available in hospitals overall was often inadequate to support medical internship training in Kenya, especially for Level 4/district or smaller hospitals. Over half reported that their hospitals did not have enough consultants, physical resources and supplies of diagnostics, equipment and medications required for their study and work. Over half of the interns experienced burnout and anxiety, some did not have good supervision at all times and had to perform inappropriate tasks, especially in smaller hospitals. Such poor internship experiences influenced MOs’ career intentions. Some preferred to leave the public sector, however the majority still preferred to work in the public sector or continue with specialist training immediately after internship. Nonetheless, as decentralisation in 2013 led to county governments being responsible for local workforce recruitment, they are not absorbing these MOs into the public sector. This is for reasons including limited health system financing, a willingness to rely on interns to provide hospital care, and preference for recruiting other cheaper health worker cadres. These findings suggest that Kenya needs to take a strategic approach to match the demand and supply of physicians, especially at labour market entry (i.e. internship) as well as improve the internship training resources and capacity. Poor planning and management not only wastes resources and undermines healthcare delivery, but can also be detrimental to individual physicians

Factors influencing the development, recruitment, integration, retention and career development of advanced practice providers in hospital health care teams: a scoping review

Background: Advanced practice providers (APPs), including physician assistants/associates (PAs), nurse practitioners (NPs) and other non-physician roles, have been developed largely to meet changing healthcare demand and increasing workforce shortages. First introduced in primary care in the US, APPs are prevalent in secondary care across different specialty areas in different countries around the world. In this scoping review, we aimed to summarise the factors influencing the development, recruitment, integration, retention and career development of APP roles in hospital health care teams. Methods: We conducted a scoping review and searched Ovid MEDLINE, Ovid Embase, Ovid Global Health, Ovid PsycINFO and EBSCOhost CINAHL to obtain relevant articles published between Jan 2000 and Apr 2023 that focused on workforce management of APP roles in secondary care. Articles were screened by two reviewers independently. Data from included articles were charted and coded iteratively to summarise factors influencing APP development, recruitment, integration, retention and career development across different health system structural levels (macro-, meso- and micro-level). Results: We identified and analysed 273 articles that originated mostly from high-income countries, e.g. the US (n = 115) and the UK (n = 52), and primarily focused on NP (n = 183) and PA (n = 41). At the macro-level, broader workforce supply, national/regional workforce policies such as work-hour restrictions on physicians, APP scope of practice regulations, and views of external collaborators, stakeholders and public representation of APPs influenced organisations’ decisions on developing and managing APP roles. At the meso-level, organisational and departmental characteristics, organisational planning, strategy and policy, availability of resources, local experiences and evidence as well as views and perceptions of local organisational leaders, champions and other departments influenced all stages of APP role management. Lastly at the micro-level, individual APPs’ backgrounds and characteristics, clinical team members’ perceptions, understanding and relationship with APP roles, and patient perceptions and preferences also influenced how APPs are developed, integrated and retained. Conclusions: We summarised a wide range of factors influencing APP role development and management in secondary care teams. We highlighted the importance for organisations to develop context-specific workforce solutions and strategies with long-term investment, significant resource input and transparent processes to tackle evolving healthcare challenges

'We were treated like we are nobody': a mixed-methods study of medical doctors' internship experiences in Kenya and Uganda

Objective: Medical interns are an important workforce providing first-line healthcare services in hospitals. The internship year is important for doctors as they transition from theoretical learning with minimal hands-on work under supervision to clinical practice roles with considerable responsibility. However, this transition is considered stressful and commonly leads to burn-out due to challenging working conditions and an ongoing need for learning and assessment, which is worse in countries with resource constraints. In this study, we provide an overview of medical doctors’ internship experiences in Kenya and Uganda. Methods: Using a convergent mixed-methods approach, we collected data from a survey of 854 medical interns and junior doctors and semistructured interviews with 54 junior doctors and 14 consultants. Data collection and analysis were guided by major themes identified from a previous global scoping review (well-being, educational environment and working environment and condition), using descriptive analysis and thematic analysis respectively for quantitative and qualitative data. Findings: Most medical interns are satisfied with their job but many reported suffering from stress, depression and burn-out, and working unreasonable hours due to staff shortages. They are also being affected by the challenging working environment characterised by a lack of adequate resources and a poor safety climate. Although the survey data suggested that most interns were satisfied with the supervision received, interviews revealed nuances where many interns faced challenging scenarios, for example, poor supervision, insufficient support due to consultants not being available or being ‘treated like we are nobody’. Conclusion: We highlight challenges experienced by Kenyan and Ugandan medical interns spanning from burn-out, stress, challenging working environment, inadequate support and poor quality of supervision. We recommend that regulators, educators and hospital administrators should improve the resource availability and capacity of internship hospitals, prioritise individual doctors’ well-being and provide standardised supervision, support systems and conducive learning environments

Blood-brain barrier-associated pericytes internalize and clear aggregated amyloid-β42 by LRP1-dependent apolipoprotein E isoform-specific mechanism

Table S1. Demographic and clinical features of human subjects used in this study. Figure S1. Aβ deposition in microvessels in AD patients and APPSw/0 mice. Figure S2. Biochemical analysis of Aβ42 aggregates. Figure S3. Cy3-Aβ42 cellular uptake in wild type mouse brain slices within 30 min. Figure S4. Pericyte coverages in Lrp1lox/lox and Lrp1lox/lox; Cspg4-Cre mice. Figure S5.. LRP1 and apoE suppression with siRNA. (DOCX 1454 kb

Characterising Kenyan hospitals' suitability for medical officer internship training: a secondary data analysis of a cross-sectional study

Objective To characterise the capacity of Kenya internship hospitals to understand whether they are suitable to provide internship training for medical doctors. Design A secondary data analysis of a cross-sectional health facility assessment (Kenya Harmonized Health Facility Assessment (KHFA) 2018). Setting and population We analysed 61 out of all 74 Kenyan hospitals that provide internship training for medical doctors. Outcome measures Comparing against the minimum requirement outlined in the national guidelines for medical officer interns, we filtered and identified 166 indicators from the KHFA survey questionnaire and grouped them into 12 domains. An overall capacity index was calculated as the mean of 12 domain-specific scores for each facility. Results The average overall capacity index is 69% (95% CI 66% to 72%) for all internship training centres. Hospitals have moderate capacity (over 60%) for most of the general domains, although there is huge variation between hospitals and only 29 out of 61 hospitals have five or more specialists assigned, employed, seconded or part-time-as required by the national guideline. Quality and safety score was low across all hospitals with an average score of 40%. As for major specialties, all hospitals have good capacity for surgery and obstetrics-gynaecology, while mental health was poorest in comparison. Level 5 and 6 facilities (provincial and national hospitals) have higher capacity scores in all domains when compared with level 4 hospitals (equivalent to district hospitals). Conclusion Major gaps exist in staffing, equipment and service availability of Kenya internship hospitals. Level 4 hospitals (equivalent to district hospitals) are more likely to have a lower capacity index, leading to low quality of care, and should be reviewed and improved to provide appropriate and well-resourced training for interns and to use appropriate resources to avoid improvising

Development assistance for human resources for health, 1990–2020

Background: Investing in the health workforce is key to achieving the health-related Sustainable Development Goals. However, achieving these Goals requires addressing a projected global shortage of 18 million health workers (mostly in low- and middle-income countries). Within that context, in 2016, the World Health Assembly adopted the WHO Global Strategy on Human Resources for Health: Workforce 2030. In the Strategy, the role of official development assistance to support the health workforce is an area of interest. The objective of this study is to examine progress on implementing the Global Strategy by updating previous analyses that estimated and examined official development assistance targeted towards human resources for health. Methods: We leveraged data from IHME’s Development Assistance for Health database, COVID development assistance database and the OECD’s Creditor Reporting System online database. We utilized an updated keyword list to identify the relevant human resources for health-related activities from the project databases. When possible, we also estimated the fraction of human resources for health projects that considered and/or focused on gender as a key factor. We described trends, examined changes in the availability of human resources for health-related development assistance since the adoption of the Global Strategy and compared disease burden and availability of donor resources. Results: Since 2016, development assistance for human resources for health has increased with a slight dip in 2019. In 2020, fueled by the onset of the COVID-19 pandemic, it reached an all-time high of USD 4.1 billion, more than double its value in 2016 and a 116.5% increase over 2019. The highest share (42.4%) of support for human resources for health-related activities has been directed towards training. Since the adoption of the Global Strategy, donor resources for health workforce-related activities have on average increased by 13.3% compared to 16.0% from 2000 through 2015. For 47 countries identified by the WHO as having severe workforce shortages, the availability of donor resources remains modest. Conclusions: Since 2016, donor support for health workforce-related activities has increased. However, there are lingering concerns related to the short-term nature of activities that donor funding supports and its viability for creating sustainable health systems

Examining the relationship between malaria burden and domestic spending on malaria in 106 countries, 2000-2019

Background: In 2019, there were 231 million (95% uncertainty interval [UI] 186–290) new malaria cases across the 106 malaria-endemic countries worldwide. Since 2000, malaria control and elimination has been a priority for the international community. This has driven global health leadership to invest in prevention, treatment, and surveillance strategies. However, as countries move from malaria control to elimination, financing sources shift from mainly development assistance for health and out-of-pocket spending to government and prepaid private spending. We aimed to examine the association between malaria burden and spending on malaria prevention and treatment activities. Methods: Malaria incidence, prevalence, and mortality rates were extracted from the 2019 Global Burden of Diseases, Injuries, and Risk Factors Study. We extracted data from 546 data sources on government, out-of-pocket, and prepaid private malaria spending; cost of patient care; and drug prices for malaria-endemic countries from 2000 to 2019. We used panel regression methods to explore the relationship between malaria burden and domestic spending on malaria. We report all spending estimates in inflation-adjusted 2019 US$. Findings: Our preliminary results suggest a negative correlation between domestic spending and new malaria cases. Additionally, decreases in malaria incidence rates were associated with increases in investment in activities to strengthen health systems and prevent malaria re-introduction. Lastly, out-of-pocket spending had a positive correlation with incidence rates in endemic countries. Interpretation: As countries succeed in reducing the malaria burden, prioritising investments in malaria surveillance and prevention is paramount to strengthen health systems, prevent resurgence, and provide financial protection to people affected by malaria. Funding: Bill & Melinda Gates Foundation

Evaluating factors that influenced the successful implementation of an evidence-based neonatal care intervention in Chinese hospitals using the PARIHS framework

Background: Evidence based interventions (EBIs) can improve patient care and outcomes. Understanding the process for successfully introducing and implementing EBIs can inform effective roll-out and scale up. The Promoting Action on Research Implementation in Health Services (PARIHS) framework can be used to evaluate and guide the introduction and implementation of EBIs. In this study, we used kangaroo mother care (KMC) as an example of an evidence-based neonatal intervention recently introduced in selected Chinese hospitals, to identify the factors that influenced its successful implementation. We also explored the utility of the PARIHS framework in China and investigated how important each of its constructs (evidence, context and facilitation) and sub-elements were perceived to be to successful implementation of EBIs in a Chinese setting. Method: We conducted clinical observations and semi-structured interviews with 10 physicians and 18 nurses in five tertiary hospitals implementing KMC. Interview questions were organized around issues including knowledge and beliefs, resources, culture, implementation readiness and climate. We used directed content analysis to analyze the interview transcript, amending the PARIHS framework to incorporate emerging sub-themes. We also rated the constructs and sub-elements on a continuum from “low (weak)”, “moderate” or “high (strong)” highlighting the ones considered most influential for hospital level implementation by study participants. Results: Using KMC as an example, our finding suggest that clinical experience, culture, leadership, evaluation, and facilitation are highly influential elements for EBI implementation in China. External evidence had a moderate impact, especially in the initial awareness raising stages of implementation and resources were also considered to be of moderate importance, although this may change as implementation progresses. Patient experience was not seen as a driver for implementation at hospital level. Conclusion: Based on our findings examining KMC implementation as a case example, the PARIHS framework can be a useful tool for planning and evaluating EBI implementation in China. However, it’s sub-elements should be assessed and adapted to the implementation setting

Examining liminality in professional practice, relational identities, and career prospects in resource-constrained health systems:Findings from an empirical study of medical and nurse interns in Kenya

We examine new doctors’ and nurses’ experiences of transitioning from training to practising as health professionals, drawing on the concept of liminality. Liminality is a stage of ‘in-betweenness’, involving uncertainty and ambiguity as people leave one social context and reintegrate into a new one. Surprisingly little research hasexplored new health professionals’ experiences of liminality during role and career transitions, particularly in precarious and resource-constrained settings. Drawing on 146 qualitative interviews and seven focus groups, involving 121 new graduate medical doctors and nurses transitioning through internship training in Kenya, wedescribe three aspects of liminality. First, liminal professional practice, where interns realise that best practices learned during medical and nursing schools are often impossible to implement in resource constrained health care settings; instead they learn workarounds and practical norms. Second, liminal relational identities, whereinterns leave behind being students and adopt the identities and responsibilities of qualified professionals within pre-existing professional hierarchies of status and expertise. We explain how these new doctors and graduate nurses negotiate their liminal status, including in relation to more experienced but less qualified professionalcolleagues. We also discuss how interns cope with liminality due to disappointing and inadequate supervision and role modelling from senior colleagues but then find peer support and their place within their own professions. Finally, we discuss how new doctors and nurses come to terms with the precarity of working in resourceconstrained health systems, abandon expectations of secure, permanent employment and careers, and accept the realities of liminal professional careers. We explain how all three forms of liminality influence professionals’ developing practices, identities, and careers. We call for further studies with a specific liminality lens to explore this critical period in health workers’ careers, to inform policy and practice responding to global transformations in healthcare professions and practice

Maternal experience of intermittent kangaroo mother care for late preterm infants: a mixed-methods study in four postnatal wards in China

Objective To describe how mothers of late preterm infants experienced the provision of intermittent kangaroo mother care (KMC) in four postnatal wards in different hospitals in China, under a pilot KMC project. Design A concurrent mixed-methods approach incorporating quantitative maternal questionnaires and qualitative semistructured interviews. Setting Four postnatal wards in level-III hospitals based in different provinces of Southeast and Northwest China. Participants All 752 mothers who provided intermittent KMC to their late preterm newborns in the four participating postnatal wards consented to participate in the study (quantitative component), as well as six nurses, two obstetricians and two mothers from two of the participating postnatal wards (qualitative component). Outcome measures Maternal KMC experiences during a hospital stay, patients’ perceptions of KMC initiation, processes, benefits and challenges. Results Most mothers had not heard of KMC before being introduced to it in the postnatal ward. On average, mothers and newborns stayed in postnatal wards for 3.6 days; during their stay, mothers provided an average of 3.5 KMC sessions, which is an average of 1.1 sessions a day. Each KMC session lasted an average of 68 min, though there was much variation in the length of a session. Common reasons given for discontinuing a KMC session included restroom use, infant crying and perceived time limitations. Some mothers would have preferred to provide KMC for longer periods of time and nurses encouraged this. Most mothers experienced no difficulty providing KMC, received support from family and medical staff and intended to continue with KMC postdischarge. Conclusion In order to improve the maternal experience of KMC, it is recommended that raising awareness of KMC should be included in antenatal care and after birth. Longer periods of KMC provision should be encouraged, greater privacy should be provided for mothers providing KMC in postnatal wards and family members should be encouraged to support KMC