Daniel Palazuelos

5-SPICE: the application of an original framework for community health worker program design, quality improvement and research agenda setting

Introduction Despite decades of experience with community health workers (CHWs) in a wide variety of global health projects, there is no established conceptual framework that structures how implementers and researchers can understand, study and improve their respective programs based on lessons learned by other CHW programs. Objective To apply an original, non-linear framework and case study method, 5-SPICE, to multiple sister projects of a large, international non-governmental organization (NGO), and other CHW projects. Design Engaging a large group of implementers, researchers and the best available literature, the 5-SPICE framework was refined and then applied to a selection of CHW programs. Insights gleaned from the case study method were summarized in a tabular format named the ‘5×5-SPICE chart’. This format graphically lists the ways in which essential CHW program elements interact, both positively and negatively, in the implementation field. Results The 5×5-SPICE charts reveal a variety of insights that come from a more complex understanding of how essential CHW projects interact and influence each other in their unique context. Some have been well described in the literature previously, while others are exclusive to this article. An analysis of how best to compensate CHWs is also offered as an example of the type of insights that this method may yield. Conclusions The 5-SPICE framework is a novel instrument that can be used to guide discussions about CHW projects. Insights from this process can help guide quality improvement efforts, or be used as hypothesis that will form the basis of a programs research agenda. Recent experience with research protocols embedded into successfully implemented projects demonstrates how such hypothesis can be rigorously tested. This paper is part of the thematic cluster Global Health Beyond 2015 - more papers from this cluster can be found at http://www.globalhealthaction.net

Addressing the "Global Health Tax" and "Wild Cards": Practical Challenges to Building Academic Careers in Global Health.

Among many possible benefits, global health efforts can expand the skills and experience of U.S. clinicians, improve health for communities in need, and generate innovations in care delivery with relevance everywhere. Yet, despite high rates of interest among students and medical trainees to include global health opportunities in their training, there is still no clear understanding of how this interest will translate into viable and sustained global health careers after graduation. Building on a growing conversation about how to support careers in academic global health, this Perspective describes the practical challenges faced by physicians pursuing these careers after they complete training. Writing from their perspective as junior faculty at one U.S. academic health center with a dedicated focus on global health training, the authors describe a number of practical issues they have found to be critical both for their own career development and for the advice they provide their mentees. With a particular emphasis on the financial, personal, professional, and logistical challenges that young “expat” global health physicians in academic institutions face, they underscore the importance of finding ways to support these career paths, and propose possible solutions. Such investments would not only respond to the rational and moral imperatives of global health work and advance the mission of improving human health but also help to fully leverage the potential of what is already an unprecedented movement within academic medicine.

Community health worker programmes after the 2013–2016 Ebola outbreak

The 2013–2016 Ebola virus disease outbreak in West Africa exposed an urgent need to strengthen health surveillance and health systems in low-income countries, not only to improve the health of populations served by these health systems but also to promote global health security.1 Chronically fragile and under-resourced health systems2 enabled the initial outbreak in Guinea to spiral into an epidemic of over 28 616 cases and 11 310 deaths (as of 5 May 2016)3 in Guinea, Liberia and Sierra Leone, requiring an unprecedented global response that is still ongoing. Control efforts were hindered by gaps in the formal health system and by resistance from the community, fuelled by fear and poor communication. Lessons learnt from this Ebola outbreak have raised the question of how the affected countries, and other low-income countries with similarly weak health systems, can build stronger health systems and surveillance mechanisms to prevent future outbreaks from escalating.4 Factors that were important in the growth and persistence of the Ebola virus outbreak were lack of trust in the health system at the community level, the spread of misinformation, deeply embedded cultural practices conducive to transmission (e.g. burial customs), inadequate reporting of health events and the public’s lack of access to health services.1 Community health workers are in a unique position to mitigate these factors through surveillance for danger signs and mobilization of communities when an outbreak has been identified. In this paper we make the case for investing in robust national community health worker programmes as one of the strategies for improving global health security, for preventing future catastrophic infectious disease outbreaks and for strengthening health systems.

Navigating and circumventing a fragmented health system: the patient's pathway in the Sierra Madre Region of Chiapas, Mexico.

Mexico has implemented several important reforms in how health care for its poorest is financed and delivered. Seguro Popular, in particular, a recently implemented social insurance program, aims to provide new funds for a previously underfunded state-based safety net system. Through in-depth ethnographic structured interviews with impoverished farmers in the state of Chiapas, this article presents an analysis of Seguro Popular from the perspective of a highly underserved beneficiary group. Specific points of tension among the various stakeholders--the government system (including public clinics, hospitals, and vertical programs), community members, private doctors, and pharmacies--are highlighted and discussed. Ethnographic data presented in this article expose distinct gaps between national health policy rhetoric and the reality of access to health services at the community level in a highly marginalized municipality in one of Mexicos poorest states. These insights have important implications for the structure and implementation of on-going reforms.

User Perceptions of an mHealth Medicine Dosing Tool for Community Health Workers.

Background Mobile health (mHealth) technologies provide many potential benefits to the delivery of health care. Medical decision support tools have shown particular promise in improving quality of care and provider workflow. Frontline health workers such as Community Health Workers (CHWs) have been shown to be effective in extending the reach of care, yet only a few medicine dosing tools are available to them. Objective We developed an mHealth medicine dosing tool tailored to the skill level of CHWs to assist in the delivery of care. The mHealth tool was created for CHWs with primary school education working in rural Mexico and Guatemala. Perceptions and impressions of this tool were collected and compared to an existing paper-based medicine dosing tool. Methods Seventeen Partners In Health CHWs in rural Mexico and Guatemala completed a one-day training in the mHealth medicine dosing tool. Following the training, a prescription dosing test was administered, and CHWs were given the choice to use the mHealth or paper-based tool to answer 7 questions. Subsequently, demographic and qualitative data was collected using a questionnaire and an in-person interview conducted in Spanish, then translated into English. The qualitative questions captured data on 4 categories: comfort, acceptability, preference, and accuracy. Qualitative responses were analyzed for major themes and quantitative variables were analyzed using SAS. Results 82% of the 17 CHWs chose the mHealth tool for at least 1 of 7 questions compared to 53% (9/17) who chose to use the paper-based tool. 93% (13/14) rated the phone as being easy or very easy to use, and 56% (5/9) who used the paper-based tool rated it as easy or very easy. Dosing accuracy was generally higher among questions answered using the mHealth tool relative to questions answered using the paper-based tool. Analysis of major qualitative themes indicated that the mHealth tool was perceived as being quick, easy to use, and as having complete information. The mHealth tool was seen as an acceptable dosing tool to use and as a way for CHWs to gain credibility within the community. Conclusions A tailored cell phone-based mHealth medicine dosing tool was found to be useful and acceptable by CHWs in rural Mexico and Guatemala. The streamlined workflow of the mHealth tool and benefits such as the speed and self-lighting were found to be particularly useful features. Well designed and positioned tools such as this may improve effective task shifting by reinforcing the tasks that different cadres of workers are asked to perform. Further studies can explore how to best implement this mHealth tool in real-world settings, including how to incorporate the best elements of the paper-based tool that were also found to be helpful.

Service training mentorship: first report of an innovative education-support program to revitalize primary care social service in Chiapas Mexico.

Background The Mexican mandatory year of social service following medical school, or pasantía, is designed to provide a safety net for the underserved. However, social service physicians (pasantes) are typically unpracticed, unsupervised, and unsupported. Significant demotivation, absenteeism, and underperformance typically plague the social service year. Objective Compañeros en Salud (CES) aimed to create an education-support package to turn the pasantía into a transformative learning experience. Design CES recruited pasantes to complete their pasantía in CES-supported Ministry of Health clinics in rural Chiapas. The program aims to: 1) train pasantes to more effectively deliver primary care, 2) expose pasantes to central concepts of global health and social medicine, and 3) foster career development of pasantes. Program components include supportive supervision, on-site mentorship, clinical information resources, monthly interactive seminars, and improved clinic function. We report quantitative and qualitative pasante survey data collected from February 2012 to August 2013 to discuss strengths and weaknesses of this program and its implications for the pasante workforce in Mexico. Results Pasantes reported that their medical knowledge, and clinical and leadership skills all improved during the CES education-support program. Most pasantes felt the program had an overall positive effect on their career goals and plans, although their self-report of preparedness for the Mexican residency entrance exam (ENARM) decreased during the social service year. One hundred percent reported they were satisfied with the CES-supported pasantía experience and wished to help the poor and underserved in their careers. Conclusions Education-support programs similar to the CES program may encourage graduating medical students to complete their social service in underserved areas, improve the quality of care provided by pasantes, and address many of the known shortcomings of the pasantía. Additional efforts should focus on developing a strategy to expand this education-support model so that more pasantes throughout Mexico can experience a transformative, career-building, social service year.Background The Mexican mandatory year of social service following medical school, or pasantía, is designed to provide a safety net for the underserved. However, social service physicians (pasantes) are typically unpracticed, unsupervised, and unsupported. Significant demotivation, absenteeism, and underperformance typically plague the social service year. Objective Compañeros en Salud (CES) aimed to create an education-support package to turn the pasantía into a transformative learning experience. Design CES recruited pasantes to complete their pasantía in CES-supported Ministry of Health clinics in rural Chiapas. The program aims to: 1) train pasantes to more effectively deliver primary care, 2) expose pasantes to central concepts of global health and social medicine, and 3) foster career development of pasantes. Program components include supportive supervision, on-site mentorship, clinical information resources, monthly interactive seminars, and improved clinic function. We report quantitative and qualitative pasante survey data collected from February 2012 to August 2013 to discuss strengths and weaknesses of this program and its implications for the pasante workforce in Mexico. Results Pasantes reported that their medical knowledge, and clinical and leadership skills all improved during the CES education-support program. Most pasantes felt the program had an overall positive effect on their career goals and plans, although their self-report of preparedness for the Mexican residency entrance exam (ENARM) decreased during the social service year. One hundred percent reported they were satisfied with the CES-supported pasantía experience and wished to help the poor and underserved in their careers. Conclusions Education-support programs similar to the CES program may encourage graduating medical students to complete their social service in underserved areas, improve the quality of care provided by pasantes, and address many of the known shortcomings of the pasantía. Additional efforts should focus on developing a strategy to expand this education-support model so that more pasantes throughout Mexico can experience a transformative, career-building, social service year.

Test result management in global health settings.

Across the globe, the ways in which patients’ test results are managed are as varied as the many different types of healthcare systems that manage these data. The outcomes, however, are often not too dissimilar: too many clinically significant test results fall through the cracks. The consequences of not following up test results in a timely manner are serious and often devastating to patients: diagnoses are delayed, treatments are not initiated or altered in time, and diseases progress. In resource-poor settings, test results too commonly get filed away within the paper chart in ways that isolate them and prevent passage to future providers caring for a patient. To make matters worse, the onus to act upon these test results often rests on patients who need to return to the clinic within a specified timeframe in order to obtain their results but who may not have the means or are too ill to do so. Even in more developed healthcare settings that use electronic records, clinical data residing in the electronic medical record (EMR) are often stubbornly “static”—-key pieces of clinical information are frequently not recognized, retrieved, or shared easily. In this way, EMRs are not unlike paper record systems, and therefore, EMRs alone will not solve this problem. To illustrate this problem, consider the case of a patient newly diagnosed with HIV in 3 different healthcare delivery settings.

The Health Implications of Deportation Policy

The United States detains and deports over 400,000 people annually. This large-scale effort has important consequences for the health of affected individuals and communities. A growing body of research suggests that deportation increases stress and mental illness, economic deprivation, and individual exposure to violence, while also contributing to destabilization and crime at the community level. The challenges to reintegration experienced by deportees are additional push factors that increase their desire to re-emigrate. Furthermore, the related destabilization of local communities also contributes to the push, not just for deportees, but for all affected people in the region. This phenomenon has important implications for the long-term effectiveness of current U.S. deportation policies, which may be contributing to destabilization in home countries and thus potentiating further unauthorized emigration to the U.S.

Validity and Utility of the Patient Health Questionnaire (PHQ)‐2 and PHQ‐9 for Screening and Diagnosis of Depression in Rural Chiapas, Mexico: A Cross‐Sectional Study

Background Depressive disorders are frequently under diagnosed in resource‐limited settings because of lack of access to mental health care or the inability of healthcare providers to recognize them. The Patient Health Questionnaire (PHQ)‐2 and the PHQ‐9 have been widely used for screening and diagnosis of depression in primary care settings; however, the validity of their use in rural, Spanish‐speaking populations is unknown. Method We used a cross‐sectional design to assess the psychometric properties of the PHQ‐9 for depression diagnosis and estimated the sensitivity and specificity of the PHQ‐2 for depression screening. Data were collected from 223 adults in a rural community of Chiapas, Mexico, using the PHQ‐2, the PHQ‐9, and the World Health Organization Quality of Life BREF Scale (WHOQOL‐ BREF). Results Confirmatory factor analysis suggested that the 1‐factor structure fit reasonably well. The internal consistency of the PHQ‐9 was good (Cronbachs alpha > = 0.8) overall and for subgroups defined by gender, literacy, and age. The PHQ‐9 demonstrated good predictive validity: Participants with a PHQ‐9 diagnosis of depression had lower quality of life scores on the overall WHOQOL‐BREF Scale and each of its domains. Using the PHQ‐9 results as a gold standard, the optimal PHQ‐2 cutoff score for screening of depression was 3 (sensitivity 80.00%, specificity 86.88%, area under receiver operating characteristic curve = 0.89; 95% confidence interval [0.84, 0.94]). Conclusion The PHQ‐2 and PHQ‐9 demonstrated good psychometric properties, suggesting their potential benefit as tools for depression screening and diagnosis in rural, Spanish‐speaking populations.

Reducing dosing errors and increasing clinical efficiency in Guatemala: first report of a novel mHealth medication dosing app in a developing country

Background Medication errors are known to be a widespread problem affecting patient safety and treatment efficacy. We were approached by a Guatemalan clinic interested in piloting an app to aid their junior clinicians in correctly calculating medication dosages. Methods We programmed a medication-dosing app using CommCare. In a prospective study among junior physicians at a small high-throughput clinic, we primarily assessed the apps dosing accuracy and efficiency. Secondarily, we measured the apps usability and effect on patient-centredness. Results Six clinicians aged 21–24 tested the app. Among 366 prescriptions, dosages were 40% more likely to be correct when calculated using the app (relative risk: 1.39; 95% CI 1.16 to 1.68; p=0.0005). Accuracy improved from 64.7% (N=156) to 92.4% (N=210). Using the app in a time-constrained context improved clinician efficiency by over 20% with a decrease in average consultation time of 1.5 min (p<0.0001) to 5.23 min on average (N=178). However, questionnaires revealed most clinicians did not believe the app improved efficiency, and none thought its recommendations were ‘always accurate’. No change in patient-centredness was observed (N=167). Conclusions The app was shown to be safe and efficient. Making this app available to junior physicians may significantly improve patient safety by enhancing dosing accuracy. This study demonstrates that dosing apps can be an efficacious means of decreasing medication errors in developing countries. We found that different strategies to introduce novel apps to providers might improve providers’ trust in the technologies and thereby make apps more efficacious.